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(February 2002) A woman in Indonesia who receives contraceptive pills at her local clinic or a man in Zambia who buys condoms at a kiosk is not likely to know how these supplies came to be there. In less developed countries, many consumers rely on free or low-cost supplies made available by governments and international donor agencies as part of efforts to improve people’s reproductive health.
Current levels of support, however, may be inadequate. Reproductive health experts are concerned about looming shortages of condoms and other contraceptives in less developed countries. The shortages are imminent because of the combined effects of growing numbers of contraceptive users, the spread of HIV/AIDS, declining levels of donor funding, and weaknesses in logistics systems. If not addressed, shortfalls in supplies could result in an upsurge of unplanned pregnancies and sexually transmitted infections, including HIV/AIDS.
An international consensus has emerged that urgent actions are needed to ensure the long-term availability of contraceptives and of condoms for HIV/AIDS prevention. In May 2001, a meeting of technical experts, donor agencies, and government health officials endorsed actions in four areas — advocacy, national capacity building, financing, and donor coordination. Continued work on this issue focuses on developing country-specific strategies that bring together the national and international partners who play a role in bringing supplies to those who need them.
International and National Support for Reproductive Health
The past few decades have seen large increases in the proportion of couples in less developed countries using family planning, from fewer than 10 percent of couples in the 1960s to nearly 60 percent today. The increase has been due to changing aspirations about family size and the success that organized family planning programs have had in bringing modern contraceptive methods — including hormonal pills and injectables, intrauterine devices, condoms, and other methods — to communities everywhere. Increasingly, couples also use condoms to protect themselves from sexually transmitted infections, particularly HIV/AIDS.
A number of international conferences sponsored by the United Nations (UN) have supported the right of men and women to attain the highest standards of reproductive health and to have access to the information and services that make good health possible. The 1994 International Conference on Population and Development, held in Cairo, was the largest and most comprehensive meeting ever to address reproductive health issues.
The Cairo agreement affirms the right of men and women to be informed about safe, effective, affordable, and acceptable methods of family planning and calls for “universal access to reproductive health care.”1 It calls on the reproductive health community — international donors, technical and service delivery agencies, and health advocates — to develop a coordinated system for ensuring supplies of the products that men and women need to achieve and maintain reproductive health. Achieving these goals requires concerted efforts to bring supplies and services to the people who need them.
Most less-developed countries import their contraceptives, including condoms, and rely on some external financing; only a few — such as China, India, and Brazil — rely extensively on local production or domestic financing of imports. In most low-income countries, a sufficient supply of contraceptives depends on product donations and grants or loans from international donor agencies and development banks. Funding from these sources fluctuates and is insufficient to meet growing need.
The Growing Gap in Contraceptive Supplies
Anecdotal evidence is accumulating from family planning programs in a number of places, including Ethiopia, Tanzania, Mexico, Thailand, and Francophone Africa, indicating that “stockouts” of contraceptives are not isolated events but rather a growing reality (Box 1 details the consequences of these shortages).2 A combination of factors contributes to the growing shortfall of contraceptive supplies.
More people of reproductive age
Past population growth in less developed countries has resulted in the largest-ever generation of young adults, who are just beginning their reproductive years. More than 1 billion young people are between the ages of 15 and 24, and an even larger group of youth will soon follow them. Therefore, even if the percentage of couples using contraceptives remains constant in the future, the number of users will grow simply because of population growth.
According to UN projections, the number of women of reproductive age (those ages 15 to 49) in less developed countries will rise by 23 percent between 2000 and 2015.3 The increases will be greatest in sub-Saharan Africa, which has the highest rate of population growth, and in Asia, which has the largest number of people. In all regions, population growth is mainly occurring among those least able to pay for reproductive health services.
Growing interest in contraceptive use
As more couples wish to delay and limit childbearing, the demand for modern contraceptives is rising. The UN estimates that the proportion of couples using contraceptives will grow 18 percent from 2000 to 2015. The number of contraceptive users over this period is projected to increase more than 40 percent as a consequence of both population growth and an increase in the proportion of people using contraception4 (see Figure 1).
Contraceptive Users in 2000 and 2015, Less Developed Countries
Source: UNFPA, based on World Population Prospects: The 1998 Revision.
The number of contraceptive users is projected to increase more than 40 percent by 2015, due to both population growth and increased demand for family planning.
The greatest increases will be in the poorest countries, which currently have high population growth rates and low but growing rates of contraceptive use. A recent analysis of 87 less developed countries that rely on donor financing for contraceptives predicted that the number of contraceptive users in these countries would rise by 79 percent during the next 15 years.5 The number of contraceptive users in sub-Saharan Africa is projected to rise by 200 percent by 2015.6
The HIV/AIDS Crisis
The HIV/AIDS pandemic compounds the problem of contraceptive supply shortages in less developed countries. Of the 40 million people worldwide living with HIV or AIDS, 94 percent are in less developed countries.7 Poverty, lack of knowledge, and lack of access to reproductive health supplies help fuel the spread of the virus. Health experts recognize the use of condoms as the most effective means of protection for sexually active individuals.
The United Nations Population Fund (UNFPA) estimates that the number of condoms needed to prevent HIV/AIDS and other sexually transmitted infections will more than double in the next 15 years. The costs associated with these supplies will increase commensurately, from US$239 million in 2000 to an estimated US$557 million in 2015. This total does not include the distribution costs or the training and counseling that are essential for effective use of condoms. The U.S. Agency for International Development has been a major supplier of condoms in less developed countries, but its support, along with that of other donors, has fluctuated over the years and not kept pace with growing needs.
Insufficient and Poorly Coordinated Donor Funding
The current levels of donor funding for condoms and other contraceptive supplies fall far short of the levels that the UN projects are needed for free and subsidized products. (Subsidized products are those provided at discount prices because the market price charged by the private sector exceeds what many low-income citizens can pay.) Figure 2 shows the estimated dollar requirements for contraceptives through 2015, including condoms for HIV/AIDS prevention. Substantial and steady increases in donor funding will be needed just to cover a portion of these costs for low-income countries.
The Gap in Funding for Contraceptives and Condoms for HIV/AIDS Prevention
Source: UNFPA, Commodity Management Unit, unpublished data, November 2001.
In the 1990s, donor funding for contraceptive supplies in less developed countries, including condoms, averaged 41 percent of the total supply costs. Even if the donor share is maintained, the gap between donor funding and total needs will exceed US$1 billion by 2015.
These increases may be challenging to achieve; donor funding for these supplies has been inconsistent and unpredictable in past years. Between 1992 and 1996, donor funding for contraceptive commodities increased from US$83 million to US$172 million, partly due to widespread support following the 1994 Cairo conference. However, by 1999, donor funding had dropped to US$131 million. The global decline in support for contraceptive commodities is particularly troublesome in light of the growing HIV/AIDS crisis.
Moreover, sources of donor funding have diversified. Fifteen donor agencies provided commodity support in 1999, compared with only four in 1990,8 making coordination more complex. These donors can have different budget cycles, shipment practices, products and brands, and reporting requirements. A lack of coordination between national governments and donors and among donors themselves contributes to gaps in supply, duplication of efforts, and even donations of inappropriate products. If donors could better synchronize their commodity assistance, the coordination burden on local health officials would be greatly reduced.
Inadequate Logistics Capacity in Developing Countries
Finally, ensuring that consumers have access to a sufficient supply of a range of products requires substantial technical and managerial capacity. While the distribution of products is a key strength of the private sector, the marketing of contraceptives and condoms for HIV/AIDS prevention presents a limited business opportunity because few people can pay market prices for these supplies. The majority of users in the poorest countries, and in poor regions of better-off countries, rely on supplies from local and national governments, which all too often lack sufficient resources and managerial capability to guarantee regular access for all in need.9
In some countries, decentralized health systems can compound supply problems. It may be difficult to track stock levels and rates of consumption, making forecasting more difficult and stockouts more common. Also, the countries with rapidly expanding demand for contraceptives and condoms tend to be in the poorest regions, where supply chains are often too weak to keep up with the growing number of users.10
Where governments lack commitment, skills, and funds, ensuring a sustainable supply of contraceptives is difficult (see Box 2, below). In many countries, more external assistance is needed to transfer skills in forecasting, purchasing, delivering, and managing the necessary supplies.
Ways to Bridge the Supply Gap
An international network called the Interim Working Group on Reproductive Health Commodity Security (IWG), made up of U.S.-based and international nongovernmental organizations (NGOs), technical agencies, and a private foundation, is helping to raise awareness of the problem and find solutions. The group convened a meeting in Istanbul in May 2001, in which representatives of governments and NGOs from 10 less developed countries drafted recommendations for bridging the contraceptive supply gap (see Box 3, below).
According to the IWG, the contraceptive supply challenge is not only a matter of making the funds available; it is also a matter of commitment, capacity, and coordination to ensure that supplies are made available to those most in need.11 There is no single recipe for resolving supply problems in all countries; rather, a number of solutions will need to be explored, depending on the local situation and degree of dependence on external assistance. The following are some ways to resolve supply problems.
Increase Government Commitment and Capacity
As a first step, the governments and health ministries of less developed countries need to acknowledge the importance of a supply problem and develop plans to address it. Their options are to:
- Budget more money for reproductive health commodities.
- Request additional donor assistance.
- Explore alternative financing options (discussed in greater detail below), including finding ways to increase the role of the private sector.
- Make better use of existing resources by strengthening the “supply chain.”
Governments need effective logistics management systems so that they can estimate product needs, mobilize resources, make timely purchases, and move supplies effectively to end-users. An effective supply chain can stretch limited resources by reducing losses due to overstocking, waste, damage, and theft. Improving logistics will require investments in skill building and management systems and, in many cases, assistance from international technical agencies.
Explore Alternative Financing Options
Contraceptives are paid for by three main sources: government budgets, donors, and individual users. While governments and donors are counted on to contribute, individual users are an often-overlooked source. In many places, government-supported health services make contraceptives and condoms available free or at low cost without regard to a client’s ability to pay. The result is that some well-off clients receive subsidies that they may not need, while the neediest and hardest-to-reach populations, such as young people or those living in remote areas, may receive none at all.
Alternative ways to raise and allocate resources include:
- Charging fees for contraceptives in the public sector, allowing exemptions for the neediest citizens;
- Promoting community financing of contraceptives, wherein members pool their resources (this approach has been tried in other areas of health care and may merit further investigation);
- Including contraceptives in national health insurance and social security programs, a measure that would allow for pooling resources nationwide and sharing costs between the public and private sectors; and
- Supporting expansion of the private sector.
There are several keys to expanding private-sector involvement. First, the government may need to remove barriers that impede private-sector involvement, such as taxes and unnecessary or cumbersome regulations. Second, if markets can be “segmented,” it may be possible to shift those people who can afford to pay for contraceptives from public programs to private services.
Governments can also enter into partnerships with the private sector, either by contracting with private health providers to provide some services or by supporting social marketing programs. Social marketing programs use commercial distribution systems and sales outlets to make subsidized products (purchased by governments or donor agencies) available to low-income clients.
Private-sector enterprises could participate in other ways as well. Reduced prices, greater contributions by employers, private insurance, and employer-based reproductive health programs are all approaches that deserve greater attention.12
Increase Donor Commitments and Coordination
The IWG stresses that donors must ensure that reproductive health supplies are a core component of existing and future financial commitments for reproductive health programs. UN agencies have a leading role in supporting AIDS prevention activities and in coordinating international assistance for reproductive health. Donors can work to improve the efficiency of their procurement systems and procedures. The UN and the World Health Organization (WHO) are working to finalize a short list of essential reproductive health supplies, which will guide governments as they streamline their logistics systems.
One outcome of the May 2001 meeting in Istanbul was agreement on the importance of having UNFPA play a leading role in the coordination of international commodity assistance. In addition, participants agreed to support an “online reproductive health exchange” that will allow all information about purchases of contraceptives and other reproductive health commodities to be kept in one place, thereby alerting donors and governments to impending shortfalls and allowing for better coordination.
Actions Needed on Many Levels
The May 2001 Istanbul meeting called for action in four areas: advocacy, national capacity building, financing, and donor coordination. Meeting participants agreed that there is an urgent need to build awareness and generate action and that responses must be country-specific, designed and led by governments in collaboration with donors and civil society. Implementation of national plans will require clearly defined roles, responsibilities, and accountability for all of the partner organizations involved.
Drawing from the Istanbul meeting and IWG reports, the following are possible actions by different partners to ensure the availability of future contraceptive supplies.13
- Lobby national governments to commit to an adequate and stable supply of reproductive health supplies, along with quality services.
- Participate in the development of national strategies for securing supplies.
- Educate members, constituents, or clients about the need for quality services, including a consistent supply of contraceptives and condoms, and about the importance of voicing concern over inadequate supplies and services.
- Test and evaluate innovative strategies for providing quality, cost-effective products and services.
- Develop national strategies for achieving security in reproductive health supplies in collaboration with other stakeholders, such as donors and NGOs.
- Increase budget allocations for purchasing reproductive health supplies and supporting services.
- Build capacity to forecast, finance, procure, and deliver high-quality and reliable supplies and services.
- Build on existing mechanisms for coordinating donor assistance in commodity purchases and related technical assistance.
- Work with WHO to include essential reproductive health supplies in the national essential drug list.
- Provide more funding for contraceptive supplies.
- Develop flexible and simplified procedures for purchasing commodities.
- Develop new mechanisms for pooling and coordinating international commodity purchases.
- Strive for greater consistency and coherence in policies and programs, to allow for longer-term planning on the part of recipient governments.
There is no universal solution for contraceptive supply shortages. Every country and individual program will need to craft its own strategy and action plan, taking into consideration the local situation while keeping in mind the common principles agreed on in international meetings.
Public health programs of any kind require commitment, funds, and coordinated efforts. In particular, the growing demand for family planning and the growing AIDS epidemic in many parts of the world will require attention to the most basic of tasks: providing the products to people who need them. While it is true that quality service delivery, counseling, and educational efforts are needed to make reproductive health programs effective, without the supplies, the programs cannot operate. And a loss of these programs means a loss of reproductive choices and an increase in health risks for women and men.
- United Nations, “Programme of Action of the International Conference on Population and Development (ICPD),” in Report of the ICPD (Cairo, Sept. 5-13, 1994): 7.2-7.3.
- Unpublished results of an e-mail survey compiled by Population Action International (Washington, DC: Population Action International, May 2001).
- United Nations Population Division, World Population Prospects: The 1998 Revision (New York: UN, 1999).
- UN Population Division, World Population Prospects.
- John Ross and Rudolfo Bulatao, Contraceptive Projections and the Donor Gap (Washington, DC: The Futures Group International for John Snow, Inc., 2001).
- Ross and Bulatao, Contraceptive Projections.
- Joint United Nations Programme on HIV/AIDS and the World Health Organization, AIDS Epidemic Update — December 2001, accessed online at www.unaids.org/epidemic_update/report_dec01/index.html, on Dec. 4, 2001.
- United Nations Population Fund, Donor Support for Contraceptives and Logistics 1999 (New York: UNFPA, 2000).
- Carolyn Hart et al., “Family Planning Logistics: Strengthening the Supply Chain,” Population Reports, Series J, No. 51 (Baltimore: The Johns Hopkins University School of Public Health, Population Information Program, forthcoming 2002).
- “Improving Logistics.”
- Population Action International, Meeting the Challenge — Overview: The Need for Security in Reproductive Health Supplies (Washington, DC: Population Action International, 2001).
- UNFPA, “The UNFPA Private-Sector Initiative: Exploring Ways to Facilitate Cooperation between Governments and the Commercial Sector to Expand Access to Reproductive Health Commodities,” accessed online at www.unfpa.org/tpd/ globalinitiative/pdf/privatesector99.doc, on Dec. 3, 2001.
- Adapted from “Moving Forward Together from Istanbul to Secure Reproductive Health Supplies,” statement of stakeholders participating in “Meeting the Reproductive Health Challenge: Securing Contraceptives and Condoms for HIV/AIDS Prevention,” Istanbul, Turkey, May 5, 2001; and Population Action International, Meeting the Challenge.
Lori Ashford of the Population Reference Bureau prepared this brief in consultation with the Interim Working Group on Reproductive Health Commodity Security and the U.S. Agency for International Development (USAID). Thanks are due to several individuals who provided valuable contributions and comments: Terri Bartlett, Clea Finkle, Carolyn Hart, Monica Kerrigan, Jagdish Upadhyay, Janet Vail, and Carolyn Vogel. This report has been funded by USAID under the MEASURE Communication Project (HRN-A-00-98-000001-00).
Consequences of Contraceptive Shortages
A recent analysis of 87 less developed countries that rely on donor financing for contraceptives predicted that the gap between the required and available financing for subsidized contraceptive supplies would reach 20 percent on average in the next five years.* This shortfall could leave 20 million couples without modern family planning methods and condoms for the prevention of sexually transmitted infections including HIV/AIDS.
The consequences of contraceptive shortages can be serious and even life threatening. When family planning programs lack the necessary supplies, current and potential contraceptive users may experience:
- Increased rates of unwanted pregnancies and births;
- Increased rates of abortions, especially unsafe abortions;
- Higher maternal and infant deaths and disability; and
- Increased risk of sexually transmitted infections including HIV/AIDS.
The prevention of contraceptive shortages is therefore a critical public concern. Family planning helps men and women plan pregnancies and avoid unwanted childbearing. Children survive in greater numbers when their mothers plan their pregnancies for the healthiest times of their lives and space their births at least two years apart. In places where medical care is inadequate and many women die from causes related to pregnancy and childbirth (including unsafe abortion), family planning helps reduce maternal deaths. In addition, the use of condoms can reduce the incidence of sexually transmitted infections that can lead to infertility, disability, and death.
*J. Ross and R. Bulatao, Contraceptive Projections and the Donor Gap (2001).
Growing Demand for Contraceptives in Kenya
Excerpted from Florence Machio, Parents Magazine (Kenya), no. 180 (June 2001). “Kenya is among the countries that are being phased out from donor funding in the area of contraception procurement in the next 8 to 10 years. Statistics show that Kenya relies solely on donor funding for its contraception needs. At the moment, the Kenyan government has shown particular interest and has stemmed up the fight against HIV/AIDS.
High HIV/AIDS prevalence rates have dramatically altered the dynamic of commodity supply systems and posed an enormous financial burden on health systems. According to Dr. Tenin Gakuruh, deputy director of medical services in Kenya, the country already faces a shortfall of 300 million condoms needed in the next three years. ‘We have solely been depending on donors over the years, but we need to have more government commitment in order to meet the demand that is increasing every day.’ “
Country Representatives Convene in May 2001 to Discuss “Securing Contraceptives and Condoms for HIV/AIDS Prevention”
“No one should die for want of a 3-cent condom,” said Peter Piot, director of the Joint United Nations Programme on HIV/AIDS (UNAIDS), at an international meeting to discuss looming shortages in contraceptive supplies. The meeting, organized by the Interim Working Group on Reproductive Health Commodity Security, brought together more than 100 participants from bilateral and multilateral donor agencies and private foundations, nongovernmental agencies, and government ministries. Ten less developed countries were represented: Bangladesh, Ethiopia, Indonesia, Kenya, Mexico, Nepal, Nigeria, Turkey, Vietnam, and Zambia.
The subject of the meeting was “contraceptive security.” Analogous to food security, the term is defined as 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 to food security is apt: In less developed countries, where thousands of people per day become infected with HIV and where a woman’s lifetime risk of maternal death is as high as one in seven, condoms and other contraceptives are lifesaving devices.
Officials at the meeting agreed that a supply crisis exists, and that no agency acting alone can ensure a secure supply and choice of high-quality health products. Organizations at the local, national, and international levels need to work together to obtain the necessary supplies to enable individuals to protect their reproductive health.
Source: “Moving Forward Together from Istanbul to Secure Reproductive Health Supplies,” statement of stakeholders participating in “Meeting the Reproductive Health Challenge: Securing Contraceptives and Condoms for HIV/AIDS Prevention,” Istanbul.