Family Planning: Progress, Lessons Learned, & the Unfinished Agenda

Presentation to the Allan Rosenfield Award CeremonyAssociation of Reproductive Health Professionals, Planned Parenthood Federation of America National Medical Committee, Society of Family Planning Annual Meeting: Reproductive Health 2009

J. Joseph Speidel, MD, MPHUCSF Bixby Center for Global Reproductive Health1 October 2009, Los Angeles, CA

Faculty Disclosure

J. Joseph Speidel has no financial interests or affiliations to disclose.

Note: Additional faculty, staff, and committee disclosures printed in final program.

Learning Objectives

At the conclusion of this session, participants should be able to:

– Understand political & policy environment during early years of foreign aid for population & family planning programs.

– Describe the strategic planning processes for funding in two major programs: USAID & the Hewlett Foundation.

Learning Objectives (continued)

– Describe background & history of family planning and reproductive health programs and institutions.

– Describe the results of USAID-supported research on new fertility regulation methods.

– Understand the lessons learned over 40 years of population policy research and programs.

– Identify unfinished agenda for population, family planning, abortion & reproductive health.

Messages of This Presentation

Career Highlights

Family Planning and Population Progress

The Unfinished Agenda

U.S. Agency for International Development, 1969-1983

Director, Research Division

Director, Office of Population

Key Colleagues:

Rei Ravenholt, Duff Gillespie, Tom Merrick, Steve Sinding, Sarah Clark, Sara Seims, Elizabeth Maguire, Jarrett Clinton, Tim Sprehe, Randy Backlund

Six USAID Program Goals

1) Demographic & Social Data• Demographic and Health Surveys

2) Population Policies• Social Science Research

3) Means of Fertility Control• Sterilization, IUDs, condoms and microbicides

• $6 million to improve abortion – prostaglandins, antiprogestins and manual uterine aspiration (MUA)

• Family Health International for clinical trials

USAID Program Goals (cont’d)

4) Delivery of Family Planning Services• Operations research

• Service delivery through developing country governments, UNFPA & NGOs (e.g. IPPF, Pathfinder, Engender Health)

5) Information & Knowledge• Population Communication Services and Population

Information Program

6) Human & Institutional Capacity• Training through multiple institutions

USAID Funds

1969, first year at AID: annual budget = $50 million

1983, final year at AID: annual budget = $250 million

Population Action International (PAI), 1983-1995

Vice President

President

Key Colleagues:

Sharon Camp, Craig Lasher, Catherine Cameron, Patty McGrath, Bob Engleman, Susan Rich, Bob Wallace, Shanti Conley

PAI Strategies

Focus on policy… both for damage control & advocacy

– 150 studies, wall charts, & fact sheets

– 750 interviews for print media

– 250 radio, TV, & personal appearances

PAI Studies

Major countries (e.g. China, India)

Major institutions (e.g. USAID, World Bank)

Studies of funding needs for ICPD– first UN Conference to identify funding targets

The William & Flora Hewlett Foundation, 1995-2003

Directed population program

“Triple A Strategy”:Advocacy Adolescents Abortion

Key colleagues:

Wendy Sheldon, Tamara Fox, Nicole Gray

Hewlett Foundation Programs

Grew from 90 projects with $20 million to 200 projects with $100 million

Population advocacy programs in all major foreign aid donor countries

Increase of $200 million in annual funding for population assistance from non-U.S. donor governments

Hewlett Foundation Programs

Advanced degree programs

Funder’s Network on Population, Reproductive Health and Rights

Foundation’s support for population work increased: 1995 = $100 million annually since 1999 = $300-500 million annually

Hewlett Foundation Programs

Contraceptive development research

Environmental organizations to explore population & environment links

Advocacy for education in developing countries – USAID education budget increased from

$100 to $200 million

UCSF Bixby Center for Global Reproductive Health, 2003-present

Director for Communication, Development & External Relations

200 faculty and staff $45 million budget Working on:

Family PACT program, emergency contraceptive information, population & environment links, funding needs, advocacy for USAID, and LARC with Cynthia Harper & Kirsten Thompson

Family Planning: A 40 Year Report Card

“In our field there is always good news and bad news…”

– Sharon Camp

Policy & Programs

1969* 2009

USAID budget $50 million $545 million

UNFPA budget $5 million $700 million

Governments in support of family planning

About 50 About 185

* The USAID Office of Population and UNFPA were established in 1969.

Family Planning Delivery Systems

1969 2009

• Small scale government& NGO programs

• Private health care providers

• Large scale government & NGO programs

• Private health care providers

• Social marketing• Household & community

distribution• Use of field workers

Changes in Family Planning in Developing Countries

1969 2009

Proportion of couples using family planning

35% 61%

Number of couples 75 million 630 million

Annual expenditures on family planning programs

$1-2 billion $8 billion

Number of couples in need of family planning

200 million 200 million

Needed funding increase $4 billion $4 billion

Changes in Total Fertility Rates

1950 1969 2009

Children per woman, developed countries

2.8 2.2 1.7

Children per woman, developing countries

6.2 5.2 2.7

Source: Population Division of the Department of Economic and Social Affairs of the United Nations Secretariat. 2009. World Population Prospects: The 2008 Revision

Population Size & Growth by Year

1900 1950 1969 2009

Developed countries

0.5 billion 0.8 billion 1.0 billion 1.2 billion

Developing countries

1.1 billion 1.7 billion 2.6 billion 5.6 billion

Annual growth

15 million 48 million 75 million 83 million

Why Does This Unfinished Agenda Matter?

Human rights– Women’s status, health, & welfare

Health– Poor reproductive health is a leading cause of illness & death

Socioeconomic development– Rapid population growth hampers economic growth,

perpetuating poverty

Environment– Growth of human numbers & consumption

The Most Critical Problems

Environmental sustainability requires stabilized population

Many of the poorest countries, mainly in sub-Saharan Africa, still have high fertility

Family planning now a lower priority for international development organizations

Most governments in poor countries have appropriate family planning policies, but insufficient funds

Adapted from: Cleland J, et al. Family planning: the unfinished agenda. The Lancet 2006; 368: 1810-27.

Unintended Pregnancies Contribute to Population Growth

Millions each year World U.S.

Pregnancies 210 6.4

Unintended pregnancies 80 3.1

Abortions 42 1.3

Unplanned births 34 1.4

Total population growth 83 2.7

Unmet Need for Abortion Care

Deaths among women subsequent to unintended pregnancy, 1995-2000

Due to unsafe abortion 400,000

Due to pregnancy, labor, delivery or other causes

300,000

Source: Daulaire N, Leidl P, Mackin L, Murphy C, Stark L. Promises to keep: the toll of unintended pregnancies on women’s lives in the developing world. Washington D.C.: Global Health Council; 2002.

What We Need to Do

The keys to effective family planning programs: – High-level political commitment

– Broad support from leadership groups

– Adequate funding

– Smaller families & modern contraception legitimized through mass media, etc.

– Availability of a variety of methods through medical facilities, social marketing, & outreach services

– Abortion care

Adapted from: Cleland J, et al. Family planning: the unfinished agenda. The Lancet 2006; 368: 1810-27.

Family Planning Services Funding Lower Now than in 1995

Source: UNFPA & NIDI Resource Flows for Population Activities.

Warnings About Population & Environment from Scientists

“Earth is finite… Its ability to provide for growing numbers of people is finite. And we are fast approaching many of the earth’s limits… We must stabilize world population.”

– World Scientists Warning to Humanity, 1992 Signed by 1700 scientists, including 104 Nobel Prize winners

“If we do not stabilize population in voluntary, humane ways, it will be done for us by Nature; it will be done brutally, relentlessly and whether we wish it or not.”– Henry W. Kendall, 1992 Nobel Laureate & Chairman of the Union of Concerned Scientists

Recent Headlines

“Starvation ravages East Africa”– TheStar.com 8/26/09

“Asia facing unprecedented food shortages, UN report says…population expected to grow by 1.5 billion over next 40 years”

– The Guardian 8/27/09

“Amazon destruction accelerating” – BBC News 5/19/05

“Climate Change Study: Poor Nations Need $500 Billion”– SF Chronicle 9/2/09

Millennium Ecosystem Assessment

Humans have changed ecosystems rapidly and extensively over the past 50 years

Increasing demands for:

– Food– Fresh water– Timber– Fiber– Fuel

Forests Are Dwindling

Global forest cover has declined by 50% since pre-agricultural times

Food Security Deteriorating

The FAO estimates there are 900 million chronically hungry people

In 15 African countries, 35% are hungry

In developing countries, 1 in 3 children under 5 years old suffer stunting

Fisheries Are Collapsing

75% of global fisheries have been over-fished or fished to their biological limit

Cropland Shrinking Due to Soil Erosion & Desertification

The productive capacity of 25% of all agricultural lands—an area equal to the size of India and China combined—has already been degraded

By 2025, 3/4 of people will face some degree of water scarcity

Overuse depleting aquifers in China, India, and the U.S.—countries with half the world’s people and the largest grain producers

Melting glaciers and decreased snow melt threaten irrigation

Water Shortage a Growing Problem

Water Scarcity Increases with Population & Climate Change

Climate change alone will increase water scarcity

Climate change plus population growth will cause further scarcity

Source: Rogers P. “Facing the Freshwater Crisis.” Scientific American August 2008: 46-53.

Crop and Range Lands Already Less Productive

Grain production peaked in 1984 at 342 kg/person

In 2006, it was 302 kg/person

1950 2008 2050

Population (billions) 2.6 6.7 9.2

Hectares/person 0.23 0.10 0.073

Climate Change Will Cause Further Food Security Deterioration

Historical record high temperatures may become the norm by 2100

1˚ Celsius increase in norms will likely cause a 2.5-16% decrease in crop yield

More destructive storms will damage crops, destroy topsoil

10 meter sea level rise could:– displace 600+ million people– flood large areas of cropland & rice-farming floodplains

Climate Stabilization Is Essential

We have much of the needed technology

Move to electric economy powered by: • Wind• Photovoltaic• Other renewables (hydro, geothermal, biomass)

Improve transportation by investing in:• High speed electric trains• Bicycle and pedestrian friendly streets • Plug-in hybrid cars

Raise energy efficiency of appliances, lighting, heating of homes and buildings

Reuse and recycle materials

Minimize consumption of meat

New Economies Can Restore Natural Systems

Sequester carbon by replanting forests

Rebuild soil through plantings & improved farming practices

Restore fisheries with marine reserves & protected coral reefs & wetlands

Preserve fresh water resources by improving irrigation practices & developing sanitary composting toilets (2.6 billion people now lack sanitation facilities)

Cost of Inaction Will Be High

Every year:– Half a million women die, 5 million suffer serious illness from

complications of unsafe childbirth & abortion– 80 million women experience unintended pregnancy

Population growth will threaten:– Social & economic progress– Preservation of the environment– Efforts to improve women’s health & welfare

A world with 11 billion people in 2050

A Strategy for Family Planning: The Three P’s

Perfect – through research

Promote – through advocacy

Provide – through universal availability

“To save ourselves we don’t need new technology: we just need the political will to face up to our problems of population and the environment.”

– Jared Diamond, 1/1/2005 “The Ends of the World as we Know Them” The New York Times

Yes We Can

Thank you!