The missing billions?

Was Cairo just a paper promise?

Posted: 30 August 2000

Author: Population Action International

The promise of the Cairo Conference was to spend $17 billion a year on population programmes by the end of the century. Population Action International reports on the world's response.

At the International Conference on Population and Development (ICPD) held in Cairo in 1994, the international community agreed to increase funding for reproductive health care. Six years after the conference, some countries have increased spending on reproductive health services but the international community as a whole is far from the ICPD year 2000 funding goals. The majority of the donor and developing countries need to increase their spending dramatically to meet the conference goal of providing reproductive health services to all who need them.

"Without resources…the Programme of Action will remain a paper promise." So said Dr. Nafis Sadik, Executive Director of the UN population Fund and Secretary General of the International Conference on Population and Development (ICPD) as that meeting came to an end in Cairo in the summer of 1994.

Clearly, changes in policies and programmes in countries such as India, South Africa and Brazil lie at the heart of the Cairo action plan. Yet Dr Sadik's words underscore the essential need for commitment of adequate funds by both developing and developed countries if the conference goals are to be turned into a reality.

Funding goals

While little information is available regarding developing country expenditures, UNFPA estimated that these countries spent about $7.9 billion on reproductive health in 1996 and $7.7 billion in 1997. The preliminary 1998 estimate of $8.6 billion represents more than 75 per cent of their year-2000 share of the total annual financial commitment agreed to in Cairo. The donor community, in contrast, had reached only one-third of its year-2000 goal by 1998. Overall, the Programme of Action called for a total of $17 billion in annual spending from all sources by 2000, followed by further increases to $22 billion in annual spending by 2015. The large funding increases anticipated in Cairo reflected the projected doubling of the number of women, men, and adolescents in need of services, and the consensus that existing efforts must be improved as well as expanded to include other reproductive health services.

© Michael MacIntyreThe Programme of Action estimated that family planning services would require roughly two-thirds of these projected resource needs, with the remaining third going to support an expanded (although still limited) package of related health services, such as basic maternity care and prevention of AIDS and other sexually transmitted infections. The Programme also called for donor countries to increase their share of contributions from the current one-fourth to about one-third, or to $5.7 billion in the year 2000. The Cairo estimates were all expressed in 1993 constant dollars; resource needs in current dollars would be significantly higher.

These estimates do not include a price tag for the broader social investments - for example on child survival and girls' education - that encourage couples to have smaller families and to delay childbearing. Yet these approaches are an integral part of the strategy agreed on at Cairo, and will require significant additional investments by both donor and developing countries.

If $17 billion a year sounds like a lot of money for global population programmes, keep in mind that the world spends $40 billion annually - roughly two and half times this amount - to play golf!

The billion-dollar question: what progress have we made, six years later, toward meeting the resource needs identified in the conference document?

Bilateral donors

The Cairo document clearly stimulated a major boost in donor contributions for population activities, following a period of relative stagnation in the early 1990s. Between 1993 and 1994, overall donor contributions jumped by 25 per cent to $1.2 billion. A number of countries increased their contributions again in 1995, including Denmark, Germany, Japan, the Netherlands, the United Kingdom, and the United States - all countries that have provided long-standing support to population work. Australia also significantly increased its bilateral assistance, while Switzerland made more modest increases. Following these initial increases, however, bilateral donor assistance levels have remained essentially unchanged since 1995 and stood at roughly $1.6 billion in 1998. If development bank loans are included, then total assistance increased from $1.3 billion in 1993 to an annual average of $2 billion through 1998. These amounts lag far behind the $5.7 billion goal for 2000 agreed to at Cairo.

In the wake of the Cairo conference, Dr. Michael Bohnet, then Deputy Director General of the German Ministry for Economic Co-Operation and Development, pointed out that the Cairo conference spurred Germany to quadruple its population assistance between 1990 and 1995. "Cairo was one of the most successful UN conferences ever. Germany now has more than 20 population and family planning projects in developing countries. This would not have happened without Cairo - the conference changed our national policies." Then, in 1999, the German Government announced a four-year austerity budget that appeared certain to negatively affect population assistance. Confronted by a concerted advocacy and public education campaign, however, the German Government partly restored funds cut from its contribution to UNFPA, and announced an allocation of DM 100 million for HIV/AIDS prevention programs.

The United States - the largest bilateral donor to population programmes - almost doubled its assistance for family planning between 1992 and 1995, to $583 million, while also increasing funding for AIDS and maternal health programmes. Then, in a major setback, the U.S. Congress cut family planning funding by a third for 1996 and has held funding stagnant ever since. More recently, family planning aid has been burdened by abortion-related restrictions that effectively reduced bilateral spending in the year 2000 to $372.5 million. Despite the cut in bilateral aid, however, U.S. assistance rose slightly because Congress agreed to restore the U.S. contribution to the UNFPA to the 1998 level of $25 million, after being zeroed out in 1999. Overall U.S. population assistance for family planning, maternal health and HIV/AIDS programs totals roughly $650 million.

Unfortunately, Cairo appears to have had minimal impact on several countries that have historically been laggards in population assistance - among them, France, Italy, Spain, and Austria. While encouraging, increases in support for UNFPA from France, Spain and Italy are still minimal compared with what these countries could do - and in comparison with their overall foreign aid commitments. Canada and Finland have moved to reverse declines in population aid, but have not restored funding to previous peak levels, while there have been some encouraging developments regarding tentative increases in political and financial support from Belgium. Population assistance provided by Norway and Sweden dipped in the mid-1990s but is now on the upswing. These countries still rank among the highest per capita contributions.

If the year 2000 funding goal for population assistance is divided according to each country's share of the combined gross national product (GNP) for the industrialized countries, only Norway, Denmark, Sweden and the Netherlands are close to paying their fair share. Even the largest contributors are far behind where they need to be. Equal burden-sharing would have required that the United States increase its population and reproductive health aid to roughly $1.9 billion in 2000. This compares to its peak contribution of about US$742 million in 1995 for population, AIDS and maternal health programmes - prior to the cuts to international family planning assistance in place since 1996. Japan would have had to increase its contribution of $103 million in 1995 for population and AIDS programmes to $1.2 billion. However, in July of this year, Japan announced a five year, $3 billion initiative to combat HIV/AIDS, and other diseases - this is in addition to Japan's current $400 million spending on health, population and nutrition.

One somewhat positive development came in the 1999 Development Cooperation Report, that showed an increase in development aid to $52 billion in 1998, reversing a declining trend that had lasted more than five years. Although the total aid level rose, however, the proportion that donor nations provided as a per centage of their GNP dropped to 0.25 per cent - less than the average of 0.33 per cent maintained during the past two decades and far lower than the 0.7 level endorsed by the United Nations.

Multilateral potential

Given the uncertain future of bilateral population aid, multilateral sources take on an even greater importance. The Cairo conference spurred the European Union (EU) - which previously provided little population funding - to announce an annual goal of ECU $300 million (US $375 million) in aid to population programmes by the year 2000, and to steadily increase its funding. Actual spending (as opposed to commitments) still lagged far behind that figure in 1997, however, at less than US $100 million.

The multilateral development banks also represent a potential source of additional funds. The World Bank increased its funding for population and reproductive health to about $500 million in 1996, up from $424 million in 1994 and is also committing large sums to girls' education. World Bank lending fell to record low levels in 1997 when lending for population and reproductive health fell to $232 million but staged a recovery to $425 million in 1998 and $446 million in 1999. The regional development banks have lent very little for population projects over the years, but the Asian Development bank is increasing its lending and gave $33 million in 1997. Private foundations are playing an increasing role in the mobilization of resources, contributing just over $100 million in 1997. These foundations include Ford Foundation, the Rockefeller Foundation, the MacArthur Foundation, the Hewlett Foundation and the Mellon Foundation and the Packard Foundation. In addition, the Melinda and Bill Gates Foundation and the UN Foundation, (established to administer media entrepreneur Ted Turner's gift to the United Nations) have also emerged as important reproductive health donors.

Developing countries

In the final analysis the main responsibility for funding population programmes falls squarely on the developing countries themselves. Indeed, about 75 per cent of costs are currently borne by them - primarily by governments, and to a lesser extent by private consumers.

However, a lack of good data on national financial commitments makes it difficult to evaluate the extent to which the developing world overall is meeting its share of the funding increases called for in Cairo. This highlights the urgent need for more systematic efforts to track expenditures for family planning and other reproductive health programmes, in order to hold both developing and donor countries accountable for meeting the goals agreed to in Cairo.

Another aspect of developing country spending is that a small number of large countries still account for a sizeable proportion of regional totals. For instance, the combined expenditures of China, India, Indonesia, the Islamic Republic of Iran and Mexico amounted to $5.5 billion, approximately 80 per cent of the entire estimate of $6.8 billion mobilized from domestic resources in 1996.

Clearly, many developing country governments could increase their contributions. Many governments spend just pennies per person on family planning, despite its importance to health and development. In much of Latin America, private consumers bear most of the cost of family planning; in most African countries, governments still look to external donors to finance their fledgling programmes.

Consumers could also contribute more. Evidence from many countries - including several relatively poor ones - suggests that private citizens are both willing and able to pay at least some share of the cost of contraceptive services.

Need for partnerships

While wealthier developing countries can bear more of the costs, the poorest countries will continue to need external assistance for some time to come. And donor nations do have a special responsibility. One cannot escape the fact of their wealth, with roughly 20 per cent of the world's people and yet 80 per cent of the world's GNP. The need for external assistance is heightened further by the impact of the AIDS pandemic, that has far outpaced the $1.3 billion set as a funding goal at the time of the Cairo conference.

With its overarching goal of improving individual quality of life, the Cairo Programme of Action is about increasing the range of choices available to each person as they pursue their productive and reproductive lives. The social investments required to make these choices available are significant, but pale beside the human costs of doing nothing. To meet the challenge of raising the resources required to meet the goals set at the ICPD in 1994, everyone will have to pay more - donor and developing country governments and citizens. Ultimately, the issue - for both rich and poor - comes down to political will.

Bangladesh: poor country - big effort

In the early 1990s, Bangladesh, a desperately poor country of 120 million people, spent a total of more than $135 million a year on family planning now used by a remarkable 45 per cent of Bangladeshi women.family planningFamily Planning, Matlab, Bangladesh© Mark Edwards/Still PicturesThe government, which has consistently made family planning a high priority, spent about $32 million a year from its own funds on the national family planning programme during this period. The World Bank and more than a dozen other donors provided another $100 million annually in loan and grant assistance for both family planning and other maternal and child health services. And private citizens spent almost $4 million a year from their own pockets to buy (mostly subsidized) contraceptives on the market. Bangladesh has shown that it is possible to mobilize signicant resources for population work, even in a very poor country, with sufficient political will.