Donor Support for Contraceptives and Condoms for STI/HIV Prevention 2009

Publication date: 2009

Donor Support for Contraceptives and Condoms for STI/HIV Prevention 2009 2 Acknowledgements UNFPA is grateful for all of the invaluable contributions to this report, which would not have been possible without the active engagement and support of countless donors and agencies. Nor would the annual report have been possible—or as useful—without the guiding efforts of Jagdish Upadhyay, Chief of UNFPA‘s Commodity Security Branch. Also within UNFPA, special thanks go to Kabir Ahmed and Daniel Assefa for coordinating with donors and other stakeholders to collect, compile and clean data. The text of the donor support report was written by Christina Vrachnos with the support of the rest of the Commodity Management Branch. 3 TABLE OF CONTENTS List of Tables and Graphs . 4 List of Acronyms . 5 I. Executive Summary with Highlights . 6 II. Background . 8 The Role of Reproductive Health Commodities . 8 Global Donor Support Database . 9 III. Introduction . 10 IV. Patterns and Trends in Donor Support . 10 Overall Patterns and Trends By Commodity Type . 10 Patterns and Trends By Donor . 15 Patterns and Trends by Region . 19 V. Donor Support for Male and Female Condoms . 26 Patterns and Trends in Donor Support for Condoms versus Other Contraceptives . 26 Male Condoms . 27 Female Condoms . 28 VI. Comparison of Contraceptive Needs and Donor Support . 29 4 LIST OF TABLES AND FIGURES Tables Table 1. Trend in Donor Expenditure By Major Commodity Method, 2000-2009 . 11 Table 2. Trend in Donor-Financed CYP By Major Commodity Method, 2000-2009 . 13 Table 3. Trend in Commodity Support Among Major Donors, 2000-2009 . 14 Table 4. Trend in Commodity Support Among Regions, 2000-2009 . 20 Table 5. Per Capita Donor Support By Region, 2009 . 21 Table 6. Top 10 Recipient Countries By Total Expenditure, 2000-2009 . 22 Table 7. Top 10 Recipient Countries By Per Capita Expenditure, 2000-2009 . 22 Table 8. Quantities of Male Condoms (in millions) Provided By Donors, 2000-2009 . 27 Table 9. Donor Expenditure on Female Condoms (in US$ thousands) By Region, 2001-2009 . 28 Table 10. Quantities of Female Condoms (in thousands) Provided By Donors, 2001-2009 . 29 Figures Figure 1. Trend in Donor Expenditure By Commodity, 2000-2009 . 11 Figure 2. Trend in Commodity Quantities Procured By Donors, 2000-2009 . 12 Figure 3. Trend in Donor-Financed CYP, 2000-2009. 13 Figure 4. Trend in Commodity Support Among Major Donors, 2000-2009 . 14 Figure 5. Distribution of Commodity Expenditures Among Donors, 2009 . 15 Figure 6. Distribution of Commodity Expenditures Among Donors, 2000-2009 . 15 Figure 7. Quantity of Male Condoms Supplied By Donor, 2009 . 16 Figure 8. Quantity of Oral Contraceptives Supplied By Donor, 2009 . 16 Figure 9. Quantity of Injectables Supplied By Donor, 2009 . 16 Figure 10. Quantity of Female Condoms Supplied By Donor, 2009 . 17 Figure 11. Quantity of IUDs Supplied By Donor, 2009 . 17 Figure 12. Quantity of Implants Supplied By Donor, 2009 . 17 Figure 13. Distribution of Donor Support For Three Major Commodities, 2009 . 18 Figure 14. Commodity Support By Method Among Four Major Donors, 2009 . 19 Figure 15. Trend in Commodity Support By Region, 2000-2009 . 20 Figure 16. Distribution of Commodity Support Among Regions, 2009 . 21 Figure 17. Distribution of Commodity Support Among Regions, 2000-2009 . 21 Figure 18. Regional Distribution of Units of Male Condoms, 2009 . 23 Figure 19. Regional Distribution of Units of Female Condoms, 2009 . 23 Figure 20. Regional Distribution of Units of Oral Contraceptives, 2009 . 23 Figure 21. Regional Distribution of Units of IUDs, 2009 . 24 Figure 22. Regional Distribution of Units of Injectables, 2009 . 24 Figure 23. Regional Distribution of Units of Implants, 2009 . 24 Figure 24. Regional Distribution of Commodity Methods (Expenditures), 2009 . 25 Figure 25. Distribution of Expenditures on Commodities Within Regions, 2009 . 25 Figure 26. Donor Support for Condoms vs. Other Contraceptives, 2000-2009 . 26 Figure 27. Donor Expenditures on Male Condoms, 2000-2009 . 27 Figure 28. Global Female Condom Distribution, 2004-2009 . 28 Figure 29. Comparison of Estimated Costs of Contraceptives With Actual Donor Support . 29 5 LIST OF ACRONYMS AE Arab States/Eastern Europe AF Sub-Saharan Africa AP Asia and the Pacific BMZ/KfW Federal German Ministry for Economic Cooperation and Development/Kreditanstalt für Wiederaufbau CDC United States Centers for Disease Control and Prevention CPR Contraceptive Prevalence Rate CYP Couple Year Protection DFID UK Department for International Development GFATM Global Fund to Fight AIDS, Tuberculosis and Malaria HIV/AIDS Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome ICPD International Conference on Population and Development IPPF International Planned Parenthood Federation IUD Intrauterine Device LA Latin America and the Caribbean MDGs Millennium Development Goals MSI Marie Stopes International NGO Nongovernmental Organization OCEAC Organisation de Coordination pour la lutte contre les Endémies en Afrique Centrale PSI Population Services International RH Reproductive Health SRH Sexual and Reproductive Health STI Sexually Transmitted Infection UNDP United Nations Development Programme UNFPA United Nations Population Fund UNGASS United Nations General Assembly Special Session UNPD United Nations Population Division USAID United States Agency for International Development WHO World Health Organization 6 I. EXECUTIVE SUMMARY Since 1990, the United Nations Population Fund (UNFPA) has been tracking donor support for contraceptives and condoms for STI/HIV prevention. The Fund publishes an annual report based on this donor database to enhance the coordination among partners at all levels to continue progress toward universal access to sexual and reproductive health, as set forth in the ICPD Programme of Action and, subsequently, the Millennium Development Goals. This report represents the 2009 installment of the series and has three main sections. In addition to an executive summary, background and introduction, the first section summarizes patterns and trends—by method, by donor and by region— in donor support from 2000-2009. The second section takes a closer look at donor support for male and female condoms over time and by region. The third and final section compares aggregate donor support to global contraceptive need for 2000-2009 and provides projections of contraceptive needs through 2015. Since 2001, male condoms have constituted the single largest donor expense as tracked in the donor support database. In terms of Couple Year Protection (CYP) for 2008, there was an increase in oral contraceptives and injectables, while for male condoms and IUDs, this fell. In 2009, however, there has been an increase of CYP in male condoms, reclaiming their status as frontrunner, followed closely by injectables and IUDs (more than doubled from 2008). In 2009, USAID and UNFPA together accounted for about 70% of overall donor support for contraceptives and condoms for STI/HIV. USAID was the largest supplier of oral contraceptives, while UNFPA was the largest procurer of injectables, implants, and IUDs. UNFPA and USAID were also the largest suppliers for male and female condoms. Of total donor support in 2009, 59 percent was provided through bilateral funding; 34 percentchanneled through UNFPA, and 7 percent through Social Marketing organizations. USAID is the largest individual donor and contributed 37 percent of total donor support, increasing its support by about $19 million to $87.5 million in 2009. UNFPA supplied roughly 34 percent of the grand total, decreasing its support by about $8 million to $81.1 million in 2009. The total donor support provided in 2009 increased by almost $25 million to $ 238.8 million from $ 213.7 million in 2008. In 2009, there was a strong link between commodity type and region. On the one hand, Sub-Saharan Africa,is by far the largest recipient of donor-procured quantities of female and male condoms, implants, oral contraceptives and injectables. On the other hand, implants increased dramatically in Asia Pacific, which was the largest recipient of units of IUDs, followed by the Arab States/Eastern Europe. Some highlights of the 2009 report include: Donor support in 2009 was US$ 238.8 million, approximately an 11% increase from 2008. Donor share requirements would nearly need to double in order to meet projected contraceptive need (estimated at US $408 million) in 2015. While in 2008, 80% of donor support was allocated to three types of commodities: male condoms, oral contraceptives and injectables; in 2009, there was a more diversified commodity mix. Male condoms led (30%), followed by injectables (22%), oral contraceptives (19%), implants (14%), and female condoms (12%). 7 Donor support for female condoms more than doubled (from 18 million in 2008 to 38 million in 2009), while there were notable increases for IUDs and implants. Sub-Saharan Africa received 72% (up 10%) of total support in 2009. Asia and the Pacific region received 15% (down 10%). Latin America and the Caribbean and Arab States/Eastern Europe received 8% and 4%, respectively. While the regions of Latin America/Caribbean and Arab States/Eastern Europe did not see notable changes in support, donor support for Sub-Saharan Africa increased significantly (up from US $133 million to $173 million in 2009). Asia and the Pacific, however, experienced a decline (from US $ 53 million to $37 million). 8 II. BACKGROUND Held in Cairo in 1994, the International Conference on Population and Development (ICPD) marked a major milestone in the international community‘s struggle to improve sexual and reproductive health (SRH) for all. The 179 signatories to the ICPD‘s Programme of Action agreed to a broad spectrum of interrelated, mutually reinforcing development objectives, including access to comprehensive reproductive health (RH) services as a human right. The Programme of Action also called for significant reductions in maternal mortality by 2000 and 2015. Five years later, at ICPD+5, the UN General Assembly agreed to an expanded set of benchmarks that included, among others, reducing unmet need for contraceptives and family planning services and, by 2015, a target coverage rate for skilled birth attendance of 90%. The ICPD goals are essential to achieving the reductions in poverty, hunger, disease and gender inequality set forth in the Millennium Development Goals (MDGs), which were established in the Millennium Declaration in 2000 and reaffirmed by the UN General Assembly in 2005. In fact, some of the key ICPD goals—75% reduction in maternal mortality and universal access to RH services by 2015—are explicit targets in the MDGs themselves. Unfortunately, while the year 2009 marked the 15th anniversary of ICPD, progress toward these goals and the MDGs has been uneven, and in some parts of the world, too slow. The global inequities are starkest for maternal mortality. Each year, more than 500,000 women die from treatable or preventable complications of pregnancy and childbirth.1 The vast majority of these deaths occur in sub-Saharan Africa and southern Asia.2 In sub-Saharan Africa, a woman‘s risk of dying from such complications over the course of her lifetime is 1 in 22 compared to 1 in 7,300 in the developed world.3 The inequities among regions are compounded by little progress within regions over time. Sub-Saharan Africa has witnessed a reduction of only 20 maternal deaths per 100,000 live births between 1990 and 2005. While progress in Asia and Latin America has been more rapid, these regions, on average, are not on track to achieve maternal mortality targets either. Globally, the maternal mortality ratio has dropped on average 1% per year between 1990 and 2005—a rate far below the estimated 5.5% average annual reduction required to reach ICPD goals and the MDGs.4 The Role of Reproductive Health Commodities Effective strategies to achieve global RH goals will require integrated, country-driven approaches that include: (1) expanded reach and quality of affordable reproductive health services in the context of overall health systems strengthening; (2) improved capacity to plan, implement and monitor and evaluate at country level; (3) increased government and international financial and technical resources; (4) enhanced coordination within the donor community; and (5) advocacy and changes in attitudes that prevent women and girls from exercising their RH choices. One of the critical components underpinning any strategy is the availability of affordable, quality RH commodities to all individuals who need them. Availability and access to 1 The Millennium Development Goals Report 2008 [MDG Report 2008]. 2 WHO, UNICEF, UNFPA, World Bank 2005. Maternal Mortality in 2005. 3 The Millennium Development Goals Report 2008 [MDG Report 2008]. 4 WHO, UNICEF, UNFPA, World Bank 2005. Maternal Mortality in 2005. 9 RH commodities are not only basic human rights, as established in the ICPD and MDG frameworks, but are also critical to improving related health outcomes, such as maternal health and HIV prevention. RH commodities play integral roles not only before pregnancy but also during pregnancy and childbirth. Most antenatal services, delivery and post-partum care and emergency obstetric care could not be delivered effectively and safely without appropriate RH commodities in the right place and at the right time. In addition to improving maternal and newborn health, sustainable availability and access to RH commodities has other beneficial impacts, particularly for HIV prevention. An estimated 33 million people are living with HIV worldwide, about half of whom are female.5 Similar to many developing regions worldwide, the AIDS epidemic is quickly feminizing in sub-Saharan Africa, where girls and young women face twice the risk of HIV infection as young men. With approximately 650 million people, this particular region experiences far lower life expectancies and higher age-adjusted mortality rates than the rest of the world. RH commodities, including HIV test kits and diagnostics, are critical for successful HIV prevention strategies and programmes. Male and female condoms, which can reduce risk of STIs, including HIV, are another case in point. Experience has shown that access to simple messages and training on RH and HIV/AIDS prevention, together with availability of RH commodities, including male and female condoms, can have a significant impact on women‘s health as well as the livelihoods of households in general. Because HIV/AIDS is implicated in a significant percentage of maternal deaths each year in sub-Saharan Africa, condoms have an even greater impact in preventing maternal death—directly by preventing unintended pregnancies and indirectly by preventing the spread of a major killer during pregnancy. Global Donor Support Database While the international development community works closely with governments to build national capacity for commodity planning, procurement, financing, distribution and monitoring and evaluation, many developing countries have lacked sufficient domestic financial resources to operate commodity programmes entirely on their own. Many of the least developed countries will continue to rely on continued financial support from the international community, at least over the near-term. As the lead agency in the area of SRH, UNFPA tracks this international financial support through a global donor support database. The largest database of its kind, the global donor support database has tracked over 21,000 procurement records of contraceptives, condoms for HIV prevention and other types of related RH commodities by major bilateral, multilateral and NGOs since 1990. The database records the financing organization, the recipient country, and commodity type, quantity and expenditure. UNFPA actively solicits relevant data from major donors on an annual basis; the database itself is updated continuously based on latest information. UNFPA publishes an annual Donor Support Report that summarizes and analyzes the data for the benefit of donors, national governments and other partners. UNFPA hopes that, among its many potential benefits, this annual report can help enhance coordination among donors, improve partnerships between donors and national governments, and mobilize the resources needed to ensure sufficient progress toward universal access to SRH. (N.B. This database does not capture private sector, country procurements or procurements financed by the Global Fund or World Bank.) 5 UNAIDS/WHO 2007. 2007 AIDS Epidemic Update. Published December 2007. http://data.unaids.org/pub/EPISlides/2007/2007_epiupdate_en.pdf 10 III. INTRODUCTION This report represents the 2009 installment of the Donor Support Report series. In addition to including the latest year (i.e. 2009) for which data is available, the report also updates data from previous years where new information is available. Consequently, data prior to 2009 may differ from that which appears in previous years‘ reports. A few caveats should be noted: First, this report tracks donor support, not the entire universe of global commodity procurement. Most commodities procured directly by countries, for example, are not included. This is particularly the case for large, middle-income countries, such as Brazil and others. The database currently does not include data from the Global Fund. World Bank contraceptive financing is not included since these are usually loans provided for contraceptive procurement. Secondly, while UNFPA makes every effort to obtain comprehensive, reliable and current data, some errors in reporting and maintaining such a large database inevitably occur. UNFPA reviews records to ensure accuracy, making modifications where possible when errors are evident. Such errors and adjustments occur infrequently in the database and should not have a large influence on the outcomes of this report‘s analyses. Thirdly, the data in this report pertains to the supply of commodities, not ultimate utilization. A variety of factors can affect rates of commodity utilization by end users. Finally, it should be remembered that certain commodities covered by this report are utilized for purposes in addition to, or other than, contraception. Male and female condoms, for example, are mostly procured and utilized for HIV prevention. This report does not distinguish between the dual purposes of condom use. IV. PATTERNS AND TRENDS IN DONOR SUPPORT This section examines trends in donor support for RH commodities from 2000-2009. It has three subsections. The first summarizes overall procurement trends by commodity type in terms of expenditures, quantities and approximated couple-year protection. The second examines these same data by donor; the third, by region. Overall Patterns and Trends By Commodity Type Table 1 summarizes expenditure trends for major commodity types from 2000-2009. Figure 1 represents these data pictorially. Since 2001, male condoms have constituted the single largest donor expense as tracked in the donor support database. Donor expenditures have remained roughly constant since 2001, though this figure dropped by about 4% in 2008 and increased by about 11% in 2009. The bulk of the remainder is split among oral contraceptives and injectables. Donor support for female condoms more than doubled, while there were notable increases for IUDs and implants. 11 Table 1. Trend in Donor Expenditure by Major Commodity Method, 2000-9 Expenditure, in US$ Millions Method Average 2000 - 2004 2005 2006 2007 2008 2009 Male Condoms 70.3 75.7 68.9 83.5 65.7 72.6 Oral Contraceptives 57.0 55.9 58.2 52.3 52.8 45.8 Injectables 51.4 58.9 58.4 53.3 53.2 52.6 Implants 4.2 5.5 7.2 16.2 23.3 33.4 Female Condoms 2.7 5.3 9.0 12.8 14.3 29.2 IUDs 5.6 4.3 4.0 2.5 1.7 3.2 Other* 2.3 1.8 2.8 2.6 2.7 2.1 Total 193.5 207.5 208.6 223.2 213.7 238.8 *Includes emergency contraceptives, vaginal tablets, foams/jellies, and sampling/testing of condoms Figure 2 reflects trends in the quantities of major commodities procured by donors from 2000-2009. Quantities of condoms bounced back from a marked 2008 decrease (see Section 5 for an analysis that disaggregates male and female condoms for more) and quantities for IUDs and implants increased significantly. Oral contraceptives and injectables, on the other hand, saw a decrease in 2009. 12 Table 2 and Figure 3 estimate the number of couple years of protection (CYP) afforded by donor-financed commodities. CYP is the estimated protection provided by contraceptive methods during a one-year period, based upon the volume of all contraceptives distributed during that period. The calculated CYP converts quantities into the number of years of protection that are offered. As a result, trends over time for individual commodity types should generally mirror those in Figure 2. The utility of the CYP calculation lies in enabling comparisons among units of different commodities. The estimates for condoms should be considered an upper bound, as most condoms are provided for HIV prevention. 2008 saw an increase in oral contraceptives and injectables, while CYP for male condoms and IUDs fell. 2009, however, saw an increase in male condoms, reclaiming their status as frontrunner, followed closely by injectables (though a decline by about 16% from 2008) and IUDs (more than doubled from 2008). 13 Table 2. Trend in Donor-Financed Couple Year Protection (CYP) By Major Commodity Methods, 2000-2009 CYP, in thousands Method Average 2000 - 2004 2005 2006 2007 2008 2009 Male Condoms 17,226 20,381 18,628 26,904 19,671 22,677 Oral Contraceptives 18,438 13,489 11,911 12,813 15,560 9,809 Injectables 15,554 16,772 16,922 17,353 23,613 19,809 Implants 635 651 860 2,586 3,166 5,682 Female Condoms 36 58 112 137 152 315 IUDs 17,342 46,282 7,714 16,397 8,532 18,741 Foam/Jellies 148 238 - 68 Diaphragms 73 1 1 - - 1 Vaginal Tablets 32 8 2 0 1 Total 69,484 97,880 56,148 76,258 70,694 77,033 14 Table 3 and Figures 4-6 illustrate trends in commodity expenditures among major donors from 2000-2009. USAID and UNFPA together account for about 70% of overall donor support for contraceptives and condoms for STI/HIV. Table 3. Trend in Commodity Support Among Major Donors, 2000-2009 Expenditure, in US$ Millions Method Average 2000 - 2004 2005 2006 2007 2008 2009 USAID $ 63.4 $ 68.8 $ 62.8 $ 80.9 $ 68.9 $ 87.5 UNFPA $ 61.3 $ 82.6 $ 74.4 $ 63.9 $ 89.3 $ 81.1 PSI $ 25.6 $ 28.8 $ 30.6 $ 24.9 $ 14.1 $ 17.9 BMZ/KFW $ 21.5 $ 13.1 $ 23.6 $ 24.6 $ 15.5 $ 16.2 DFID $ 11.8 $ 4.6 $ 12.1 $ 22.5 $ 11.1 $ 13.0 Others* $ 9.9 $ 9.6 $ 5.1 $ 6.4 $ 14.9 $ 23.0 Total $ 193.5 $ 207.5 $ 208.6 $ 223.2 $ 213.7 $ 238.8 *Includes IPPF, MSI, Japan, Netherlands and others. 15 16 Figures 7-12 illustrate the quantities of contraceptives, including condoms, provided by donors for 2009. USAID was the largest supplier of oral contraceptives (50%). UNFPA was the single largest procurer of injectables (65%), implants (51%), and IUDs (61%). UNFPA and USAID were also the largest suppliers for male and female condoms alike. 17 18 19 Figure 13 depicts the distribution of donor support for three major commodities in terms of expenditures in 2009. USAID, closely followed by UNFPA, is the lead agency in terms of donor support for the male and female condom, and for oral contraceptives. USAID and UNFPA are also the top supporters for injectables. Figure 14 illustrates the expenditure patterns of four major donors in 2009. The majority of USAID, UNFPA, BMZ/KfW and DFID funds were allocated to male and female condoms (US $ 73 million), followed by injectables (US $ 50 million) and oral contraceptives (US $ 44 million). Patterns and Trends by Region Table 4 and Figures 15-17 (next page) illustrate trends in commodity expenditures by region for 2000-2009. The four regions tracked are sub-Saharan Africa (AF), Asia and 20 the Pacific (AP), Latin America and the Caribbean (LA) and Arab States/Eastern Europe (AE). Sub-Saharan Africa is the largest single recipient of donor support for all years except 2000. The regions of Latin America/Caribbean and Arab States/Eastern Europe did not see substantial changes in donor support. Asia and the Pacific, however, experienced a decline (from US $ 53 million to $37 million). A decrease could also be related to countries within these regions using their own funds to procure or perhaps, contributions from a dynamic private sector. Table 4. Trend in Commodity Support Among Recipient Regions, 2000-2009 Expenditure, in US$ Millions (%) Region Average 2000 - 2004 2005 2006 2007 2008 2009 AE $ 14 $ 14 $ 11 $ 11 $ 8 $ 10 AF $ 83 $ 98 $ 89 $ 134 $ 133 $ 173 AP $ 78 $ 62 $ 73 $ 60 $ 53 $ 37 LAC $ 17 $ 21 $ 22 $ 16 $ 19 $ 18 Other/Unknown $ 1 $ 12 $ 14 $ 2 $ 0 $ 0 Total $ 193 $ 208 $ 209 $ 223 $ 214 $ 239 21 Table 6. Top 10 Recipient Countries By Total Expenditure 2005 2006 2007 2008 2009 2009 Total (US $ Million) % 2009 Total 1 Ethiopia Bangladesh Zimbabwe Ethiopia Zimbabwe $ 21.8 9.1% 2 Nigeria Pakistan Ethiopia Bangladesh Nigeria $ 17.8 7.4% 3 Bangladesh Zimbabwe Bangladesh Zimbabwe Ethiopia $ 15.7 6.6% 4 Pakistan Vietnam Nigeria Pakistan Tanzania $ 12.4 5.2% 5 Vietnam Ethiopia Pakistan Tanzania Congo, Dem. Republic $ 12.2 5.1% 6 Kenya Madagascar Kenya Nigeria Kenya $ 10.9 4.6% 7 Uganda Tanzania India Kenya Pakistan $ 9.9 4.1% 8 Tanzania India Uganda Madagascar Uganda $ 8.4 3.5% 9 Egypt Ghana Ghana Uganda South Africa $ 8.0 3.3% 10 Nepal Uganda Tanzania Mozambique Bangladesh $ 7.8 3.3% Table 7. Top 10 Recipient Countries By Per Capita Expenditure 2005 2006 2007 2008 2009 2009, Per Capita (US$) 1 Nicaragua Zimbabwe Zimbabwe Moldova Zimbabwe $ 1.59 2 Fiji Swaziland Bhutan Zimbabwe Zambia $ 0.62 3 Republic of Congo Republic of Congo Lesotho Tanzania Swaziland $ 0.57 4 Guinea Lesotho Swaziland Cote d'Ivoire Rwanda $ 0.49 5 Zimbabwe Madagascar Fiji Rwanda Malawi $ 0.44 6 Central African Republic Haiti Haiti Fiji Fiji $ 0.44 7 Cape Verde Fiji Zambia Liberia Honduras $ 0.42 8 Bhutan Suriname Cambodia Sao Tome and Principe Sao tome & Principe $ 0.42 9 Ethiopia Cape Verde Botswana Mali Lesotho $ 0.38 10 Mongolia Lao PDR Sao Tome & Principe Ethiopia Nicaragua $ 0.37 Figures 17-22 illustrate the quantities of major contraceptives, including condoms that donors provided to regions in 2009. These data show a strong association between commodity type and region. Sub-Saharan Africa, for example, is by far the largest recipient of donor-procured quantities of female and male condoms, implants, oral contraceptives and injectables. In fact, oral contraceptives quantities almost doubled, while there was a decrease in implants. On the other hand, implants increased dramatically in Asia Pacific, which was also the largest recipient of units of IUDs (47%), followed by Arab States/Eastern Europe (35%). Asia Pacific, however, saw a substantial decrease in oral contraceptives. 22 23 24 25 Figure 23 depicts the regional distribution of commodity expenditure by commodity type in 2009. Regions with less than US$ 1 million in expenditure by commodity type were excluded from the graph for ease of visual representation. Regional patterns in terms of expenditure mirror the patterns in terms of quantities procured. Figure 24 illustrates the expenditure patterns in the four regions in 2009. Among the regions, Sub-Saharan Africa received the overwhelming amount of support for all commodities: male condoms (US$ 50 million); injectables (US$ 37 million); oral contraceptives (US$ 30 million). Sub-Saharan Africa also received nearly all of the donor support for implants (US$ 29 million) and female condoms (US$ 26 million). In Asia and the Pacific, male condoms constituted the largest expenditure, closely followed by injectables and oral contraceptives. Largest donor expenditures in LACRO were split between male condoms and injectables. 26 V. DONOR SUPPORT FOR MALE AND FEMALE CONDOMS Male and female condoms, when used consistently and correctly, are highly effective at preventing STIs, including HIV. Indeed, male and female condoms are central to efforts to halt the spread of HIV as recognized at the ICPD in 1994 as well as by the UNGASS Political Declaration on HIV/AIDS, adopted unanimously by United Nations Member States on 2 June 2006. Male and female condoms are also the only methods that provide couples simultaneous protection against unintended pregnancies and STIs/HIV. In particular, the female condom is currently the only technology that gives women and adolescent girls greater control over protecting themselves from HIV, other STIs and unintended pregnancy. Comprehensive condom programming (CCP) is a key institutional priority for UNFPA, because condoms -- both male and female -- are recognized as the only currently available and effective way to prevent HIV – and other sexually transmitted infections – among sexually active people. CCP is an integrated approach consisting of demand, supply and support functions that was created to expand access and help prevent the spread of STIs. Condom Requirements According to a Reproductive Health Supplies Coalition report, where condom requirements are estimated separately (those used primarily for family planning and those used primarily for prevention of HIV and other sexually transmitted infections), total need for family planning condoms in low- and middle-income countries is estimated at almost 5 billion in 2015. The total (for both purposes) would be nearly 18 billion in 2015. Yet as large countries such as Brazil, China, India, and South Africa do not depend on donors for their condom supply, donor provided condom requirements would be nearly 4.4 billion in 2015 -- 2.4 billion for HIV prevention and 2.0 billion for family planning6. Patterns and Trends in Donor Support for Condoms versus Other Contraceptives Figure 25 shows trends in the distribution of donor support for condoms relative to other types of contraceptives. Some data may differ slightly from previous year‘s reports due to updating of database records. It is important to note that most condoms are provided and utilized for STI/HIV prevention rather than contraception. 6 Reproductive Health Supplies Coalition, Contraceptive Projections and the Donor Gap: Meeting the Challenge 2009. 27 Male Condoms Figure 26 depicts trends in donor expenditures on male condoms by region over the period 2000-2009. Total donor expenditure on male condoms appears relatively constant over the last few years. Sub-Saharan Africa received its highest levels of donor support (US$ 54 million) for male condoms in 2007, saw a dip in expenditure in 2008, yet rebounded in 2009 (US$ 50 million). 28 Table 8 summarizes the quantity of male condoms procured by donors in each region from 2000 to 2009. Donors provided a record high of over 3.1 billion male condoms in 2007, representing a sharp increase from 2006. Most of these increases have been driven by increased quantities to sub-Saharan Africa, which received over 1.7 billion male condoms in 2009. Table 8. Quantities of Male Condoms (in millions) Provided By Donors Region Average 2000 - 2004 2005 2006 2007 2008 2009 AF 1,136 1,297 1,025 2,004 1,357 1,763 AP 704 584 785 900 675 614 LAC 137 337 235 161 233 243 AE 79 86 53 90 95 100 Total 2,056 2,305 2,098 3,155 2,361 2,720 Female Condoms Table 9. Donor Expenditures on Female Condoms (in thousands) Provided By Donors Region Average 2000 - 2004 2005 2006 2007 2008 2009 AF $ 3,021 $ 3,800 $ 5,965 $ 11,798 $ 12,878 $ 26,316 AP $ 77 $ 363 $ 590 $ 465 $ 805 $ 1,439 LAC $ 100 $ 92 $ 325 $ 501 $ 411 $ 1,217 AE $ 8 $ 11 $ 36 $ 43 $ 171 $ 209 Total $ 3,206 $ 4,265 $ 6,917 $ 12,807 $ 14,265 $ 29,181 Table 10. Quantities of Female Condoms (in thousands) Provided By Donors Region Average 2000 - 2004 2005 2006 2007 2008 2009 AF 4,799 4,907 8,681 15,108 16,531 33,555 AP 132 481 848 611 952 2,203 LAC 169 115 433 679 490 1708 AE 12 14 44 49 216 346 Total 5,112 5,518 10,006 16,448 18,189 37,813 Table 9 summarizes donor expenditures for female condoms by region. Since 2001, donors have increased their support dramatically. Support more than doubled from 2008 to 2009. While the bulk of that increase has been directed to sub-Saharan Africa, the Asia and the Pacific and LACRO regions saw a sizeable increase in donor support 29 for female condoms. Table 10 summarizes the quantities of female condoms procured by donors by region. Total donor support in terms of quantities has more than doubled from 2008 levels, to over 37 million in 2009. Most of this increase has been driven by dramatic increases in support to sub-Saharan Africa, which received well over 33 million female condoms from donors in 2009. VI. COMPARISON OF CONTRACEPTIVE NEEDS AND DONOR SUPPORT This section compares donor support with estimated costs of contraception and condoms for HIV/AIDS prevention (from Reproductive Health Supplies Coalition, ―Contraceptives Projections and the Donor Gap‖, 2009). The donor support requirements were estimated for a set of 88 donor dependent countries by leveraging data sources such as the DHS surveys to estimate the current contraceptive prevalence rate, current unmet need for family planning and the current method mix of different family planning options. The projected number of users was computed using population projections, projected CPR rates for all women and projected method mixes. The population receiving service (the number of women projected to be using each type of family planning service) was multiplied by the cost of a couple year protection to estimate the family planning costs. A separate calculation was performed to estimate the number of condoms need for HIV/AIDS prevention and added to the commodity requirements. Donor funding share was estimated based on historical donor share. It is important to note that this is not meant to indicate that the historical donor share is the ―correct share‖ but rather was used as a basis for asking the question, ―what would donor costs be in the future if the donor share remained the same and the current unmet need was reduced to 0 by 2015?‖ Figure 27 clearly displays that the donor share requirements would nearly need to double in order for the current unmet need to be met in 2015. Source: Reproductive Health Supplies Coalition, ―Contraceptives Projections and the Donor Gap‖, 2009 Several factors need to be kept in mind when analyzing resource requirements in the context of available funding. Individuals‘ unmet needs for family planning, the use of standard costs and the exclusion of programming costs increase the requirements shown above; other factors, however, reduce them. The following provides a brief overview of some of the main factors that influence the estimated requirements. 30 Unmet Need The projections of family planning users assume that the current unmet need for family planning is reduced to zero by 2015. There is no assumption of latent demand. According to UNFPA estimates, approximately 2157 million women worldwide would like to limit or space the number of children they have but are not using contraceptives.8 Standard Costs The projections of commodity requirements were developed assuming unit costs paid by USAID and UNFPA in 2006. Unit costs were weighted according to the quantities procured by the two agencies. An upward adjustment of 15 percent was applied to account for transportation and wastage costs. These prices are at the very low end of the cost spectrum, which means that the actual costs might be substantially higher. Varying Degrees of Donor Dependency There are also factors that effectively change the presented donor requirements. The numbers shown in the graph were calculated based on historical donor share which may change in the future. Linking Donor Support to CPR Contraceptive prevalence in developing countries has grown dramatically in the past decades. Since the mid-1960s, the contraceptive prevalence rate has increased from approximately 10 per cent to almost 60 per cent. The United Nations Population Division projections show that the reproductive-age population in developing countries will increase some 23 per cent between 2000 and 2015. To meet current growth rates, donor funding for contraceptives will need to increase by 60 percent, from about US$230 million per year today to about US$370 million by 2020, or by more than 80 percent to more than US$420 million by 2020 to eliminate unmet need9. 7 Adding It Up, Guttmacher Institute, 2009. 8 As defined by Demographic Health Surveys, ‗unmet need‘, is the measure of the discrepancy between the number of women in surveys who respond that they would like to limit or space childbirth but are not currently using contraception. 9 Reproductive Health Supplies Coalition, Contraceptive Projections and the Donor Gap: Meeting the Challenge 2009.

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