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Family Planning: Progress, Lessons
Learned, & the Unfinished Agenda
Presentation to the Allan Rosenfield
Award Ceremony
Association 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, MPH
UCSF Bixby Center for Global
Reproductive Health
1 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
•
•
Small scale government
& NGO programs
Private health care
providers
2009
•
•
•
•
•
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
35%
61%
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
$4 billion
$4 billion
Proportion of couples
using family planning
Number of couples
Needed funding increase
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
–

Health
–

Poor reproductive health is a leading cause of illness & death
Socioeconomic development
–

Women’s status, health, & welfare
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
Water Shortage a Growing Problem
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 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:
–
–

Population growth will threaten:
–
–
–

Half a million women die, 5 million suffer serious illness from
complications of unsafe childbirth & abortion
80 million women experience unintended pregnancy
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
Yes We Can
“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
Thank you!