PAI The Future of U.S. Government Involvement Funding for FP and RH Programs

Publication date: 2008

THE FUTURE OF U.S. GOVERNMENT INVOLVEMENT & FUNDING FOR FAMILY PLANNING & REPRODUCTIVE HEALTH PROGRAMS IN THE EVOLVING U.S. AID ARCHITECTURE by Craig Lasher Over the last two years, the architecture of U.S. foreign assistance has undergone an unprecedented restructuring. At the same time, a congressionally-mandated commission on poverty-focused development has issued its report; a Senate staff delegation has conducted an extensive overseas fact- finding mission; and numerous nongovernmental organizations, think tanks, and presidential campaigns have issued policy prescriptions on the future of U.S. foreign aid. In all of these efforts, insufficient attention has been paid to the implications of actual and proposed changes in the U.S. foreign assistance program to the future priority and funding of family planning and reproductive health (FP/RH) care overseas—highly successful and cost-effective programs that have received U.S. government funding since the 1960s.1 This research commentary first describes the recent developments in U.S. foreign assistance architecture and examines the implications of policy shifts for FP/RH. The commentary analyzes funding trends for FP/RH and proposes levels of U.S. funding for FP/RH that would meet U.S. financial commitments to achieving the goal of universal access to reproductive health care by 2015 adopted by 179 governments, including the United States, at the 1994 International Conference on Population and Development. U.S. Aid Architecture and the Implications of the Foreign Assistance Restructuring Process During the early years of this decade, the architecture of the U.S. foreign assistance program was composed of a bilateral aid agency—the U.S. Agency for International Development (USAID), established in 1961 during the Kennedy administration—and voluntary and assessed contributions to multilateral institutions, principally to the United Nations and the World Bank. Soon after the inauguration of President George W. Bush, this traditional model was combined with a plethora of presidential initiatives. The most notable and well- funded of these initiatives are the multi-billion dollar President’s Emergency Plan for AIDS Relief (PEPFAR), created in 2003, and the Millennium Challenge Corporation (MCC), founded in 2004. In January 2006, the U.S. government’s foreign assistance landscape grew considerably more complex with the introduction of a major restructuring scheme, christened “transformational diplomacy” by Secretary of State Condoleezza Rice.2 Research Commentary volume 3, issue 1 MARCH 2008 Transformational diplomacy is the culmination of an effort by the Bush administration to define and institutionalize its own foreign aid philosophy. Ironically, one of the primary objectives of the restructuring has been to bring government-wide coherence and coordination to a fractured foreign assistance program that the Bush administration has itself deliberately fostered through the proliferation of over 20 presidential initiatives focused on discrete high-profile issues with political or diplomatic salience. Many of these initiatives are largely funded and managed outside USAID and the pre-existing aid architecture.3 The stated goal of transformational diplomacy is “helping to build and sustain democratic, well-governed states that will respond to the needs of their people, reduce widespread poverty and conduct themselves responsibly in the international system.”4 In reality, the new strategic framework to implement the vision of transformational diplomacy emphasizes short-term national security and democracy promotion objectives to the detriment of long-term development and poverty reduction efforts. Tellingly, the reference to poverty alleviation in the definition of the overarching goal of transformational diplomacy was added only after the fact in response to complaints from civil society about its absence. Where Do Family Planning and Reproductive Health Programs Fit in Transformational Diplomacy? Global health in general and FP/RH in particular are layered-down in the list of priorities within transformational diplomacy. The health program area falls underneath “investing in people,” one of the five programmatic objectives in the new strategic framework along with “peace and security, governing justly and democratically, economic growth, and humanitarian assistance.” FP/RH is one of eight program elements (along with HIV/AIDS, tuberculosis, malaria, avian influenza, other public health threats, maternal and child health, and water supply and sanitation) within the health program area.5 This rigid strategic framework—comprised of over 100 pages of detailed descriptions of each program objective, area, element, and sub-element— was reported to have been a response to Secretary Rice’s frustration at not being able to get an answer on how much U.S. foreign aid was being spent on democracy promotion. Unlike many other development sectors, the USAID Office of Population and Reproductive Health has always been able to supply a detailed accounting of its project portfolio in each country, due in large part to the intense scrutiny and political controversy that the program has been subjected to during various presidential administrations since its founding over 40 years ago. “In reality, the new strategic framework to implement the vision of transformational diplomacy emphasizes short-term national security and democracy promotion objectives to the detriment of long-term development and poverty reduction efforts.” Joint State Department and USAID functional committees defined the components of each of the five objectives. The FP/RH program element is described in a 2007 State Department document with the following definition: Expand access to high-quality voluntary family planning (FP) services and information, and reproductive health (RH) care. This element contributes to reducing unintended pregnancy and promoting healthy reproductive behaviors of men and women, reducing abortion, and reducing maternal and child mortality and morbidity.6 An earlier definition of the purposes of FP/RH programs had referenced “mitigating adverse effects of population dynamics on natural resources, economic growth, and state stability” as an additional benefit of the FP/RH programs, highlighting the important linkages between demographic trends and enhancing national security, promoting economic growth, and preserving the environment—three historic rationales for USAID involvement in the population field. However, all three were, inexplicably, left out of the final program element definition. The New Pre-Eminent Role of the State Department As the restructuring process has proceeded, the State Department has assumed the pre-eminent role in foreign aid program prioritization and allocation of funding, leading to a much diminished role for USAID. This change has been accelerated by the creation of the Director of Foreign Assistance (DFA) position at the State Department (with the rank of Deputy Secretary). The DFA also serves as the USAID Administrator. Some long-time observers, both inside and outside government, have described the restructuring process and the changes in the organizational chart as accomplishing a de-facto merger of USAID into the State Department.7 Development assistance proponents have long argued for the independence of USAID in order to insulate foreign aid decision- making from the short-term political and diplomatic considerations of the State Department. FP/RH advocates and programmatic experts have consistently called for an allocation of the scarce available funds among countries based on the documented unmet need for reproductive health care of their populations rather than their geopolitical significance to the United States. Nevertheless, even before the advent of transformational diplomacy, country allocations for FP/RH were sometimes distorted by the need to beef up the foreign aid amounts to U.S. friends and allies. With the State Department assuming greater control of the allocation process, this tendency will likely be magnified. Despite intentions in favor of a more field-based approach, the restructuring process has been centralized, Washington-driven, and top-down with a questionable amount of real consultation and participation by mission and embassy staff on the ground in many cases. Overall country funding allocations were set by Secretary Rice in a process that was not transparent or consultative. Under the restructuring, the role of the ambassador in coordinating the U.S. foreign assistance portfolio in country is in theory greatly enhanced, which could be a positive development under the leadership of a strong, well-informed and interested diplomat. As a result, requests from developing country governments for additional assistance for FP/RH programs from the United States could assume even greater importance and become critically important for indigenous advocacy strategies. As much as USAID may be maligned in Washington for being bureaucratic and slow in responding to new challenges, USAID mission staff play an irreplaceable role not only in carrying out USAID’s own long-term development and health programs but in backstopping a number of MCC and PEPFAR country programs due to their experience, country knowledge, and contacts in the host nation and in advising the ambassador on all foreign assistance questions.8 How Do PEPFAR and MCC Fit—or Don’t? In contrast to USAID, the funding for PEPFAR and MCC is not controlled by the Director of Foreign Assistance at the State Department, who is charged with providing guidance to all international affairs programs across the U.S. government. The Director of Foreign Assistance has only a coordinating role with regard to PEPFAR, MCC, and foreign aid programs in other cabinet departments or agencies, such as contributions to the international financial institutions housed at the Treasury Department or export promotion activities. Through different institutional and governance structures, both PEPFAR and MCC report to the Secretary of State. PEPFAR is administered by the Office of the Global AIDS Coordinator (OGAC) within the Office of the Secretary of State. MCC is an independent government corporation with a CEO and a board of directors chaired by the Secretary of State and composed of statutory (Secretary of State, Secretary of the Treasury, and the USAID Administrator) and private sector members appointed by the President and the bipartisan congressional leadership. The massive amounts of funding that have been pumped into PEPFAR since its creation in 2003—an estimated $18.8 billion through 20089 —are completely distorting the balance within the U.S. government’s global health portfolio, harming USAID’s traditional public health “In one startling example of the magnitude of funds being allocated to PEPFAR’s 15 focus countries, the amount of the President’s FY 2008 budget request for HIV/AIDS assistance to Kenya alone is more than the entire budget for USAID family planning and reproductive health programs worldwide.” programs in the FP/RH, child survival and maternal health, and infectious disease sectors by squeezing available funds and luring away many of the trained health care workers. In one startling example of the magnitude of funds being allocated to PEPFAR’s 15 focus countries, the amount of the President’s FY 2008 budget request for HIV/AIDS assistance to Kenya alone is more than the entire budget for USAID family planning and reproductive health programs worldwide.10 Given the implications for existing development programs and for the future of USAID, the MCC has been met with less than ringing endorsement in some quarters of Congress and the development community. FP/RH advocates are particularly concerned by the lack of attention paid to the needs of women and girls and the disregard for the relevance of the UN’s Millennium Development Goals (MDGs). Those concerns remain although MCC has instituted a gender policy and added a natural resource indicator to its country eligibility criteria. However, spending on health and social sector projects in MCC countries has been largely nonexistent to date, as the majority of country compacts with a few notable exceptions have focused on large infrastructure projects and reform of financial systems. Restructuring and the Policies of Other Donors The foreign assistance program restructuring under transformational diplomacy has also confirmed the U.S. government’s rejection of the trend among all other major donors, such as European governments and the World Bank, in moving away from vertical support for specific development programs like FP/RH in favor of channeling aid through broader mechanisms, such as general or sector budget support, that leave the allocation of the funding provided largely up to the countries themselves. One country example of U.S. exceptionalism in the funding mechanisms it employs to deliver its foreign assistance is Tanzania, where most multilateral organizations and every other bilateral donor except the United States provides unearmarked financial support to the Tanzanian government in support of its national health strategy through either a health sector basket fund or general budget support. USAID participates in the development partner dialogue at the country level, but its financial contribution for reproductive health programs is separate and vertically funded.11 In the health sector in particular, it is important to note that the decision not to employ these broader financing mechanisms is not merely philosophical or a result of the recent restructuring but dictated by a legislative restriction that prohibits “nonproject assistance” to supplement developing country government health budgets, included for the last five years in the annual foreign aid funding bill.12 As explained, the congressional rationale is that “the provision of cash grants as general budget support for governments is no longer an appropriate development tool, given current funding constraints,” but it also demonstrates the continuing domestic political imperative for members of the U.S. Congress to be able to direct and document how U.S. taxpayer funds are spent. FY 2008 Budget Request Reflected Foreign Aid Restructuring The total amount of U.S. foreign aid has risen significantly during President Bush’s tenure. However, much of the increased funding has been concentrated in a smaller number of countries as a result of the priority assigned to those countries either as key allies to the United States in its “global war on terror” (most notably Iraq, Afghanistan, Pakistan), as good aid performers (11 low or lower- middle income countries with MCC compacts), or as one of 15 PEPFAR focus countries. As such, the Bush administration’s budget priorities closely mirror the goals and objectives of transformational diplomacy and the foreign assistance restructuring process. The Bush administration’s FY 2008 budget request was the first budget constructed using the new strategic framework. The request concentrated increases in three primary areas—MCC, global AIDS programs, and Iraq reconstruction. The first two items consume 60 percent of the total increase for international affairs programs proposed for FY 2008 over the prior year’s total funding level. The six largest country recipients—all allies in the “global war on terror”—would have received 50 percent of total U.S. foreign assistance under the President’s budget proposal.13 It is also becoming increasingly clear that the Bush administration’s penchant for creating multiple new presidential initiatives is undermining the funding for USAID’s long-term development programs, such as FP/ RH. For example, in the FY 2008 budget request, FP/RH and child survival and maternal health programs were slated for large reductions. Meanwhile, significant funding increases were proposed for PEPFAR and a new Presidential Malaria Initiative, also targeting 15 African countries, and an avian influenza effort. This downward funding pressure on existing health programs is now more apparent despite promises that funding for these initiatives would be “additional” and not to the detriment of efforts long underway. Most notably, the President proposed a 25 percent cut to FP/RH funding for FY 2008, a $111 million reduction from the FY 2007 appropriated level of $436 million. As spelled-out in a State Department document, the rationale for the proposed reduction in the budget request for FP/RH was in recognition of “significant successes that have been achieved after 40 years of worldwide family planning efforts.” The document claims that the “decision to decrease funds to this sector was “ …much of the increased funding has been concentrated in a smaller number of countries as a result of the priority assigned to those countries either as key allies to the United States in its “global war on terror,” as good aid performers, or as one of 15 PEPFAR focus countries.” ‘demand-driven,’ that is, identified by interagency teams, with input from field missions.”14 Not only are the program’s many successes being held against it despite continued unmet need for family planning around the world, but the funding level is also an apparent victim of the restructuring of the U.S. foreign assistance program. One of the other motivations of the restructuring process was the desire to provide maximum flexibility to the executive branch in funding allocations and to break the practice of congressional earmarking of funds for favored projects, sectors, organizations, countries, or regions. This desire is a reflection in large part of the longstanding tension that has existed over the management of the U.S. foreign aid program between the executive branch and Congress. Historically, FP/RH or “population assistance” has been the poster child for congressional earmarking. (It was the last health sector to have a separate functional account in the annual foreign aid bill before being eliminated in FY 1996.) Because of the political jeopardy that FP/RH programs have often found themselves under certain Presidents, along with the perennial competition for scarce financial resources among the various programmatic sectors within USAID, FP/RH funding has always been protected by an earmark inserted by the program’s congressional champions. Despite the political attacks directed at the program, particularly vitriolic since international family planning became entangled in the U.S. domestic abortion politics in the 1980s, the FP/RH program has managed to survive. As longtime observers predicted, in passing the $516 billion omnibus spending bill for FY 2008 in December 2007, Congress rejected the new strategic framework and many of its budget recommendations, appropriated funds to the same foreign aid accounts as in previous years, and continued to earmark funds for appropriations committee members’ priorities. As a result, a specific funding level for FP/RH was included and the amount was increased rather than cut. The omnibus earmarks $457.3 million for bilateral FP/RH programs from all funding accounts, an increase of $21.7 million or five percent above the FY 2007 appropriated level of $435.6 million. Similarly, Congress earmarked $40 million for a U.S. contribution to the United Nations Population Fund (UNFPA). While the modest increase in bilateral FP/RH funding—the first of any significance during the Bush administration—is welcome, it is dwarfed by the funding increases on the order of 40 percent for a number of other health programs, including HIV/AIDS and malaria, and the near doubling for tuberculosis. At least for FY 2008, FP/RH funding has again escaped the dramatic cut proposed by President Bush, but as expected he recommended reductions of a similar magnitude when his FY 2009 budget request was submitted to Congress in February. Trends in U.S. Funding for Family Planning & Reproductive Health Total U.S. financial assistance for family planning and reproductive health programs, both bilateral and multilateral, peaked in FY 1995 when Congress appropriated $577 million, including $542 million through USAID and a $35 million contribution to UNFPA. However, bilateral funding suffered a congressionally-imposed 35 percent cut the following year when Republicans gained control of both houses of Congress for the first time in 40 years. Bilateral FP/RH funding remained low in the late 1990s and was subject to punitive funding conditions before recovering modestly and then stagnating at less than $450 million from 2001 until this year. At the same time, the U.S. contribution to UNFPA has been withheld since FY 2002 as President Bush has interpreted a legislative restriction to deny funding to the agency based on the presence of a UNFPA country program in China. When adjusted for inflation, U.S. bilateral funding for FP/RH programs in FY 2007 is 41 percent less than in FY 1995. In fact, as shown in Figure 1, due to inflation, the level of assistance has remained basically flat since the inception of U.S. funding of international FP/RH programs in 1965 if measured in constant 1974 dollars—the fiscal year that a separate population account was first added to the Foreign Assistance Act. This flat funding has occurred despite a major increase in the need and demand for FP/RH care and services. In demographic terms alone, the number of women of reproductive age in the developing world grew by 850 million to nearly 1.4 billion between 1965 and 2005.15 � ��� ��� ��� ��� ��� ��� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �� � � � � �� � � �� � � �� � � �� � � �� � � �� � � �� � � �� � � �� �� �� � � �� � � �� � � �� � � �� � � �� � � �� � � �� � � �� � � �� �� �� � � �� � � �� � � �� � � �� �� �� � � �� �� �� � � �� � � �� �� �� � � �� � � �� � � �� � � �� � 6�4��1016-"5*0/�"44*45"/$& �*/�.*--*0/4�0'�%0--"34� 61%"5&%�."3$)����� �� 505"-�6�4��"44*45"/$& 505"-�6�4��"44*45"/$&� */�$0/45"/5������%0--"34 FIGURE 1: U.S. FP/RH ASSISTANCE, IN MILLIONS OF DOLLARS16 It is important to note that while the funding allocations for selected individual countries may increase in any given year, the amount of overall funding available for USAID FP/RH programs worldwide has remained stagnant during the Bush administration. In its first five budget requests, the Bush administration requested an annual funding level of $425 million, which Congress routinely increased during the appropriations process. For the last two years, the president unsuccessfully proposed large cuts in excess of $100 million each year. As the outcome of the FY 2008 appropriations process has demonstrated, there is reason to believe that congressional family planning champions will continue, for the remainder of his administration, to reject President Bush’s large proposed cut and fight to restore funds to FP/RH programs in FY 2009. A More Appropriate Level for U.S. Contributions to Global FP/RH Efforts The contrast between the inflation-adjusted stagnant funding levels and the growing number of women of reproductive age indicates that a quantum leap is needed in the amount of financial resources allocated to FP/RH programs by the United States in order its meet its commitments made at the 1994 International Conference on Population and Development (ICPD). According to a 2003 study by the United Nations Population Fund and the Guttmacher Institute, 201 million women in developing countries have an unmet need for effective, modern contraceptives because they seek to postpone childbearing, space births, or want no more children but are not using a modern method of contraception. The added cost of providing these contraceptive services—in addition to current expenditures on FP/RH—would total $3.9 billion (in constant 2003 dollars) annually.17 If the United States were to pledge to provide its appropriate share of the total financial resources necessary to meet the unmet need for contraception of these estimated 201 million women, this sum would total about $1 billion.18 On the other hand, $3.2 billion would be the U.S. fair share of global expenditures necessary to achieve universal access to reproductive health care by the year 2015, as agreed to by the international community at the 1994 ICPD in Cairo. Universal access to reproductive health care by 2015 is also a new target recently approved by the UN General Assembly for measuring progress toward meeting Millennium Development Goal 5 on maternal health. Based on a reappraisal of the Cairo funding targets prepared for the UN Millennium Project in response to better costing data for health interventions and the distortions created by the massive infusion of donor financing to “ …due to inflation, the level of assistance has remained basically flat since the inception of U.S. funding of the international FP/RH programs in 1965 if measured in constant 1974 dollars.” address the HIV/AIDS pandemic,19 the appropriate U.S. share of $3.2 billion can be calculated.20 Conclusion A consensus has emerged that the U.S. foreign assistance program and its supporting architecture are broken and badly in need of reform. Transformational diplomacy was the Bush administration’s response and its attempt to restructure and create a new strategic framework for foreign aid. This attempt has been largely ignored by Congress and sharply criticized by key stakeholders, both inside and outside the U.S. government. Nevertheless, this consensus around the urgent need to revitalize the U.S. foreign assistance program persists so that the United States may better respond to the foreign policy and national security challenges it will increasingly face in the 21st century. Three new reports, authored by a broad array of foreign policy experts from both political parties, call for an elevation of development and diplomacy within the nation’s foreign policy, including consideration of the establishment of a cabinet-level department for foreign assistance.21 What institutional arrangement for the U.S. foreign assistance program might best support the continuation and expansion of the historic technical and financial leadership role of the United States in the global population field is beyond the scope of this commentary. Nevertheless, ensuring that FP/RH programs occupy their proper place in the new aid architecture is a policy imperative. Family planning and reproductive health need to be a much higher priority and receive stronger institutional support and significantly increased funding from the incoming Administration. Specifically, in order to meet its international commitments and pay its fair share of the ICPD funding targets necessary to achieve universal access to reproductive health care by 2015, the U.S. government needs to increase by more than six times its annual funding for FP/RH programs. The necessity of making significantly greater investments in global development and constructing an aid architecture to better fit current global demands is increasingly apparent and must be high on the foreign policy agenda of the next president. The international development community has long recognized that improving the health and well-being of individuals is not just an investment in people—it is an investment in creating a more peaceful and developed world. As PAI’s research on reproductive health and the linkages between demographic trends and development, environment, and security have suggested, such investments can yield far-reaching benefits for individuals, families, and societies and for national, regional, and global stability. Craig Lasher is a senior policy analyst at Population Action International. © 2008 Population Action International 1300 19th Street NW, Second Floor Washington, DC 20036 USA +1-202-557-3400 e-mail: research@popact.org www.populationaction.org Notes 1 For purposes of this paper, the term family planning and reproductive health and the acronym FP/RH is employed as this is the terminology used to designate the program by the U.S. government both in legislation and policy documents. 2 See U.S. State Department website for documents on “transformational diplomacy” and the restructuring of the U.S. foreign assistance program at the following link: http://www. state.gov/f/ 3 See U.S. Agency for International Development for a listing of presidential initiatives announced since 2001 at the following link: http://www.usaid.gov/about_usaid/presidential_initiative/ 4 See U.S., Department of State, “Foreign Assistance Framework,” dated July 10, 2007 at the following link: http:// www.state.gov/documents/organization/88433.pdf 5 Ibid. The new strategic framework is graphically represented in the so-called “six by five” matrix which overlays five programmatic objectives with six categories of countries defined by the their level of political stability and socioeconomic development. 6 U.S., Department of State, “Foreign Assistance Standardized Program Structure and Definitions,” dated October 15, 2007, available at the following link: http://www.state.gov/ documents/organization/93447.pdf 7 See, for example, commentaries appearing in the Foreign Service Journal: Zamora, F., “If It Quacks Like Duck . . .,” December 2006, p. 63 (http://www.afsa.org/fsj/dec06/aidvoice. pdf) and Holmes, J.A., “Tobias, Transformational Diplomacy and the Evisceration of USAI,.” June 2007, p. 5 (http://www. afsa.org/fsj/jun07/holmes.pdf). 8 U.S., Congress, Senate, Embassies Grapple to Guide Foreign Aid, (A Report to Members of the Committee on Foreign Relations), S. Prt. 110-33, 110th Cong., 1st session, November 2007, p. 8. The staff report is available at the following link: http://frwebgate.access.gpo.gov/cgi- bin/getdoc.cgi?dbname=110_cong_senate_committee_ prints&docid=f:38770.pdf. 9 U.S., Office of the Global AIDS Coordinator, “The U.S. Commitment to Global HIV/AIDS,” January 2008. See http:// www.pepfar.gov/press/81352.htm 10 Population Action International, “U.S. HIV/AIDS and Family Planning and Reproductive Health Assistance: A Growing Disparity Within PEPFAR Focus Countries,” January 2008, a fact sheet available on the PAI website at the following link http://www.populationaction.org/Issues/U.S._Policies/FPRH/ fprh.pdf 11 Project RMA, “Tanzania Country Study,” forthcoming 2008. 12 U.S., Congress, House, Legislation on Foreign Relations Through 2005, (Joint Committee Print of the Committee on International Relations and the Committee on Foreign Relations of the U.S. Senate), January 2006, Volume I-A, p. 927. See the full report at the following link: http://frwebgate. access. gpo.gov/cgi-bin/getdoc.cgi?dbname=109_cong_house_ committee_prints&docid=f:24796.pdf 13 Bazzi, S., Herrling, S., Patrick, S., “Billions for War, Pennies for the Poor: Moving the President’s FY2008 Budget from Hard Power to Smart Power,” Center for Global Development, March 16, 2007. See the full budget analysis at the following link: http://www.cgdev.org/content/publications/detail/13232/ 14 U.S. Department of State, “Summary and Highlights” document, February 2007. See: http://www.state.gov/ documents/organization/80151.pdf 15 United Nations Population Division, World Population Prospects: The 2006 Revision. 16 Population Action International, “Trends in U.S. Population Assistance,” a chart available on the PAI website at the following link: http://www.populationaction.org/Issues/U.S._ Policies/Trends_in_U.S._Population_Assistance.shtml 17 Singh, S., Darroch, J., Vlassoff, M., and Nadeau, J., Adding It Up—The Benefits of Investing in Sexual and Reproductive Health Care (New York: The Alan Guttmacher Institute, 2003), pp. 18-19. (see http://www.unfpa.org/upload/lib_pub_ file/240_filename_addingitup.pdf). 18 In order to calculate the appropriate U.S. share of financial resources required to meet the current unmet need for contraceptive services, standard practices for international burden-sharing can be applied. Additional global expenditures required in 2007, adjusted for inflation [See U.S. Bureau of Labor Statistics inflation calculator— http://data.bls.gov/cgi-bin/cpicalc.pl] = $4.42 billion Donor country share of additional global expenditures under funding goals in the 1994 International Conference on Population and Development’s Programme of Action—donor nations provide one-third of total funding = $1.47 billion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Appropriate U.S. share of additional global expenditures to meet unmet need—based on percentage of total donor country gross national income [See Organization for Economic Co-operation and Development, Statistical Annex for the 2006 Development Co-operation Report, table 38, updated January 2007— www.oecd.org/dac/stats/dac/dcrannex] = $562 million FY 2008 appropriated level for bilateral and multilateral FP/RH assistance = + $464 million Appropriate U.S. contribution to total global expenditures required to meet unmet need for contraceptives—current plus additional funds = $1.03 billion 19 Vlassoff, M. and Bernstein, S., Resource Requirements for a Basic Package of Sexual and Reproductive Health Care and Population Data in Developing Countries: ICPD Costing Revisited—Summary (New York: UN Millennium Project, 2006), pp. 1-4. (see http://www.unmillenniumproject.org/ documents/Resource_requirements-for-RH-1.pdf) 20 The appropriate U.S. share of financial resources in 2008 necessary to achieve universal access to RH care by 2015 using the reappraisal of Cairo resource requirements by Vlassoff and Bernstein can be recalculated as follows: ICPD target for total global expenditures on population assistance in 2005, adjusted for inflation, 2007 = $25.2 billion Donor country share of inflation-adjusted target—one-third of total funding = $8.4 billion Appropriate U.S. share of ICPD funding target to achieve universal access to reproductive health care by 2015—based on percentage of total donor country gross national income = $3.2 billion 21 The recent reports include the congressionally-mandated Helping to Enhance the Livelihoods of People (HELP) Commission (see: http://helpcommission.gov/portals/0/ Beyond%20Assistance_HELP_Commission_Report.pdf), a Center for Strategic and International Studies Commission on Smart Power (see: http://www.csissmartpower.org/ReportFinal. pdf), and the previously-cited the Senate staff report on the implementation of transformational diplomacy. For a matrix comparing the recommendations of the three reports, see the website of the Center for U.S. Global Engagement at the following link: http://www.usglobalengagement.org/Portals/16/ Matrix.pdf

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