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ContraceptiVE SECURITY


Securing contraceptives for economic development


“It is only through giving women greater choice and access to family planning and safer births that we will lift communities from desperate poverty.�1 Andrew Mitchell, UK Secretary of State for International Development

Key action points Ensure that targets and indicators for sexual and reproductive health and contraceptive security are included in national and regional health plans, policies and strategies. Strengthen health information systems and collect comprehensive data about the sexual and reproductive health needs of the population, disaggregated by gender, age, socio-economic status and geographic location. Ensure that there are dedicated budget lines in the national budget and loans for reproductive health commodities, including contraception, and that internally-generated funds are allocated to them.

Political will: the keystone of contraceptive security

Political will: the keystone of contraceptive security

Contraceptive security and political will

An estimated 215 million women who want to space or limit their pregnancies are not using an effective method of family planning.2 Every year, four out of every 10 pregnancies in developing countries are unintended3 and 35 million unwanted pregnancies end in abortion, more than half of them under unsafe conditions.4 Despite the evidence that family planning is one of the most cost-effective interventions, very few developing countries have achieved contraceptive security. And in the absence of contraceptive security, interventions to empower women (Millennium Development Goal 3), to improve maternal health (Millennium Development Goal 5), to tackle sexually transmitted infections, including HIV (Millennium Development Goal 6) and to advance sustainable development (Millennium Development Goals 1 and 8) are undermined.

Political commitment and funding

Political commitment and funding for family planning – at national and district levels – are desperately required to get contraceptives to those who want them. Donor support is important, but until developing countries demonstrate leadership and contribute

domestic financing for sexual and reproductive health, contraceptive security will continue to fail. In addition to increased funding, governments can demonstrate leadership and commitment by tackling inefficiencies and bottlenecks in the health system, as well as policy barriers, that prevent women and men from learning about and accessing contraception.

Financial burden for contraception

At the 2005 World Summit, 192 national governments agreed that ‘universal access to reproductive health’ (target 5b under Millennium Development Goal 5: Improving maternal health) – including family planning – is essential for development. In a study of 47 developing countries, however, only 20 reported using internally-generated funds to procure contraceptives.5 It is consumers who bear the greatest financial burden for contraception and other sexual and reproductive health services. On average, over 60 per cent of total domestic expenditure for sexual and reproductive health* in developing countries comes from consumer out-of-pocket payments.6 In Asia and the Pacific, out-of-pocket payments rise to 71 per cent of total domestic spending, and in sub-Saharan Africa, 50 per cent of domestic spending on sexual and reproductive health is paid by consumers at the point of care.7

Figure 1: Unmet need by wealth quintile


% unmet need

40 Poorest quintile

30 Richest quintile

20 10 0

Nepal (2006)

India (2005–06)

Rwanda (2005)

Ghana (2003)

Philippines (2003)

Sources USAID (2010) Inequities of accessing family planning services: a summary of DHS findings. USA: ICF Macro. Presentation available at: <> Accessed 8 June 2011. USAID (2006) New estimates of unmet need and the demand for family planning. DHS Comparative Reports 14. Available at: <> Accessed 8 June 2011.

* Includes expenditure for all sexual and reproductive health services, including family planning, reproductive and maternal health services, and services related to sexually transmitted infections, including HIV and AIDS.

Political will: the keystone of contraceptive security

Figure 2: Ghana vs Rwanda: unmet need, contraceptive prevalence rates and ideal family size

% unmet need and contraceptive prevalence

40 35

Unmet need


Contraceptive prevalence rate (modern methods, women in union)

25 20 15 10

Ideal number of children


) 08

5) (2











an Rw






8) an




3) 00 (2 a an









Table 1: Estimated domestic family planning expenditure (US$1,000) Domestic government

Non-governmental organization







Where does this leave the poorest women, men and young people? When people cannot afford contraceptives (and the costs of transport, of lost income, of child care and the other expenses that are often added to the cost of a medical consultation and supplies), they often simply go without and risk the negative health consequences of an unintended pregnancy. This burden is felt disproportionately by the poorest and most vulnerable people.8 Governments have a responsibility to lead public health information campaigns and to ensure that vulnerable populations have access to services, without incurring catastrophic health expenditures. Lack of willingness to commit a country’s own revenue to sexual and reproductive health, including family planning, represents a worrying lack of commitment to these issues that is inconsistent with the public declarations of support that these countries make in international arenas.

Ghana and Rwanda: two very different stories

Ghana and Rwanda are two countries that have given different levels of priority to family planning. This is reflected in the decline in Ghana’s contraceptive prevalence rate and the significant increase in the contraceptive prevalence rate of Rwanda. Despite increasing prosperity and declining donor funding, the government of Ghana has failed to release budgetary allocations for contraceptives in recent years. Although demand for contraceptives is rising, no internallygenerated government funds are used to cover the cost of public sector contraceptives (only donor funding and in-kind donations).9 In contrast, the government of Rwanda has spearheaded a national programme to advance contraceptive security and increase awareness of the widespread benefits of family planning. A tripling of expenditure on family planning from 2002–06 was largely due to increases in donor resources.10 The government of Rwanda also spends internally-generated funds on family planning, as well as investing in other health system inputs: these include human resources and training, a public information programme, logistics management, supervision and appropriate policies.11 In Rwanda, there are more and more new users of contraception, and women’s stated ideal family size is declining. In Ghana, however, unmet need for contraception is on the rise.

Political will: the keystone of contraceptive security



1 Department for International Development (2010) Statement delivered by Secretary of State for International Development, Andrew Mitchell, to the ECOSOC 2010 High-Level Segment. Available at: <> Accessed 10 June 2011. 2 Guttmacher Institute (2010) Facts on Investing in Family Planning and Maternal and Newborn Health. New York: Guttmacher. Available at: < FB-AIU-summary.pdf> Accessed 8 June 2011. 3 Ibid. 4 Guttmacher Institute (2011) Facts on Induced Abortion Worldwide. New York: Guttmacher. Available at: <> Accessed 8 June 2011. 5 Dowling P and Tien M (2007) Policy Brief: Using National Resources to Finance Contraceptive Procurement. Washington, DC: USAID | DELIVER Project. 6 United Nations Population Fund and Netherlands Interdisciplinary Demographic Institute (2010) Projections of Funds for Population and AIDS Activities, 2008–2010. The Hague: NIDI. Available at: <> Accessed 10 July 2008. 7 Ibid. 8 Outside of sub-Saharan Africa, rural women, women with little or no education and poor women are at a greater risk of unplanned pregnancies. There is no single pattern in the distribution of unmet need in sub-Saharan Africa. p.55. Sedgh G, Hussein R, Bankole A and Singh S (2007) Women with an Unmet Need for Contraception in Developing Countries and their Reasons for Not Using a Method. Occasional Report No. 37. New York: Guttmacher. Available at: < or37.pdf> Accessed 6 June 2011. 9 USAID | DELIVER Project (2010) Measuring Contraceptive Security Indicators in 36 Countries. Arlington, VA: USAID | DELIVER. 10 Health Systems 20/20 (2008) National Health Accounts Rwanda 2006 with HIV/AIDS, Malaria, and Reproductive Health Subaccounts. Bethesda, MD: Health Systems 20/20 Project, Abt Associates Inc. p.77. 11 USAID | DELIVER Project. Op. cit. 12 USAID (nd) Measuring Family Planning Logistics System Performance in Developing Countries. Logistics Brief. Arlington, VA: USAID. 13 World Health Organization (2010) The World Health Report: Health Systems Financing: The Path to Universal Coverage. Geneva: WHO. 14 World Health Organization Statistical Information System (WHOSIS). Contraceptive prevalence rate (percentage). Available at: < compendium/2008/3pcf/en/index.html> Accessed 2 August 2011. 15 World Health Organization (2010). Op. cit. 16 Westoff CF (2006) New Estimates of Unmet Need and the Demand for Family Planning. DHS Comparative Reports No. 14. Calverton, MD: Macro International Inc.

Contraceptive security has been achieved when individuals can choose, obtain and use quality contraceptives whenever they need them.12 Commodity security for a variety of reproductive health supplies is critical to achieve development goals. Catastrophic health expenditures relate to a household paying more than 40 per cent of household income directly on health care after basic needs have been met.13 Contraceptive prevalence rate is the proportion of women of reproductive age who are using (or whose partner is using) a contraceptive method at a given point in time.14 Out-of-pocket payments are fees paid by the consumer/patient at the point of care, at the time of accessing services. According to the World Health Organization, “continued reliance on direct payments, including user fees, [are] by far the greatest obstacle to progress.”15 Unmet need for family planning refers to women who want to avoid a pregnancy but are not using an effective method of family planning.16 Statistics around unmet need for family planning generally include only married women, aged 15–49, as data collection on demand for family planning among unmarried women is weak.

“Family planning is priority number one – not just talking about it, but implementing it.” President Kagame, Rwanda

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Photo by IPPF/Jane Mingay/Rwanda Edited and designed by Published November 2011