SWEDEN

POPULATION AND REPRODUCTIVE HEALTH ASSISTANCE OVERALL ASSESSMENT

Sweden is a pioneer in the population field–one of the first countries to provide bilateral family planning assistance and a major supporter of multilateral population and reproductive health initiatives. As other major donors have taken on more responsibility for family planning assistance, Sweden has shifted its emphasis into neglected areas such as safe delivery, safe abortion, adolescent health, sexual health education and violence against women. Sweden’s current formulation of "sexual and reproductive health and rights" is in many respects even broader than the definition of reproductive health agreed on at the Cairo conference. Today, Sweden’s approach to population and development highlights human rights and gender concerns, and is broadly inclusive of the social and economic elements which impact population and reproductive health.

Sweden’s financial allocations to population programs are difficult to assess. Reasons for this difficulty include the government’s broad definition of sexual and reproductive health and rights; the devaluation of the Swedish currency relative to the dollar; and a shift in aid mechanisms from more focused projects to sector-wide approaches. Government officials report that Sweden has maintained or increased its financial support in national currency for population-related programs following the ICPD, but the dollar value of Swedish contributions has declined owing to exchange rate changes. Even in national currency, Sweden’s contribution to UNFPA fell between 1994 and 1997, but in 1998 this trend was reversed. As the seventh largest contributor to population programs in 1996, Sweden remains an important donor in reproductive health and continues to play a pioneering role in addressing the more controversial aspects of sexual and reproductive health and rights.

1 Development Assistance: Policy and Funding

Sweden is one of the few donor nations that allocates at least 0.7 percent of GNP to development cooperation annually. Since 1996, the Swedish development assistance budget has been directly linked to GNP and, therefore, has increased in absolute terms; this trend is expected to continue to the year 2000 and beyond. Unfortunately, due to the falling value of the Swedish currency relative to the U.S. dollar, Swedish allocations have fallen in dollar terms.

Sweden has been a pioneer both in the volume of aid it has given and in the implementation of aid programs. The Swedish aid program has a reputation for being on the leading edge in adopting new development assistance program directions and innovations. For example, Sweden was among the first donors to adopt multi-year funding commitments and a recipient-oriented approach to designing projects. Sweden was also one of the first donors to fund programs in the areas of NGO cooperation, women in development, the environment, democracy and human rights.

In recent years, aid management has been increasingly streamlined. In the past, the administration of Sweden’s aid program involved many actors. The Swedish Parliament has always played an important function in setting overall policy for development cooperation and approving annual budget allocations. The Ministry of Foreign Affairs, through its Department for International Development Cooperation, has responsibility for policy development, multilateral organizations, and development programs in Eastern Europe and the former Soviet Union. Prior to 1995, the remainder of the aid program was administered through various agencies, of which the largest was the Swedish International Development Agency (SIDA). Traditionally, SIDA disbursed half of all Swedish development assistance funds and three-quarters of all bilateral aid.

Concerns with the efficiency of aid administration led in 1995 to the creation of a new entity called "Sida." This new entity merged the old SIDA and four other agencies involved in the Swedish development program, with the aim of improving the efficiency of aid administration and eliminating the overlapping responsibilities these agencies had in many of the same cooperating countries. Sweden’s 1995 membership in the European Union (EU) also provided an impetus for reorganizing and improving the efficiency of its aid bureaucracy.

After declining since 1992, Sweden’s aid budget appears to have stabilized at about 0.7 percent of GNP. During the early 1990s, Sweden experienced economic difficulties including high unemployment, and, for the first time, saw some decline in public support for foreign aid. Although budget cuts in domestic programs played a major role in these changes in attitudes, the Swedish public had also become concerned with the lack of clear successes resulting from their foreign aid program. Public debates focused on aid effectiveness and the problem of aid dependency among recipient countries. As a result, Sweden’s official development assistance declined from a high of almost $2.5 billion in 1992 to $1.7 billion in 1997. However, cuts to the foreign aid budget were smaller than those in other areas, and Swedish development assistance continues to meet or exceed the 0.7 percent goal which most other donor nations have failed to reach.

2 The Policy Environment for International Population Assistance

The Swedish government was one of the first bilateral donors to provide population assistance, initiating funding for contraceptive commodities and services in the 1950s and 1960s. In the 1970s, the Swedish government became concerned about the ethics of funding family planning programs in countries which reportedly used coercive approaches. Swedish women’s groups were also critical of the government’s support for international family planning programs following reports of sterilization abuses in countries such as Bangladesh and India. As a result, Swedish population assistance fell to a low of $17 million in 1985, before slowly recovering and rising to a high of $62 million in 1992.

Sweden is one of only a few donor nations with official policy statements on both population and reproductive health. In 1997, Sida published two position papers, Population, Development and Cooperation and a Strategy for Sexual and Reproductive Health and Rights. In these documents, Sweden rejects the premise that population problems can be solved solely by contraceptive programs and describes four priority areas it perceives as linked to population and the ICPD recommendations: poverty alleviation; peace, democracy and human rights; gender equality; and sustainable development.

Sweden’s conceptualization of sexual and reproductive health and rights is even broader than the vision adopted by the ICPD Programme of Action. For example, while other donors have family planning programs, Sida refers to the broader concept of "fertility regulation," which includes both delaying or preventing childbearing through contraception as well as the safe termination of unwanted pregnancies.

Parliamentarians and high-ranking policy makers appear supportive of Sida’s broad conceptualization of population and reproductive health, and the casting of reproductive rights as an issue of human rights and gender equality. In 1996, the parliament passed a formal resolution endorsing the promotion of equality between women and men in partner countries as a new goal for development cooperation.

3 Trends in Funding for Population Assistance

Overall Funding Levels:

Trends in Swedish funding for population programs are difficult to assess, both because of Sweden’s very broad definition of population activities, as well as the falling value of the Swedish currency against the dollar. Swedish officials report that contributions to sexual and reproductive health and rights and HIV/AIDS programs rose between 1994 and 1997 in national currency. However, UNFPA data indicate that Swedish contributions have declined in dollar terms. In addition, Sweden did not provide data on its population assistance levels to UNFPA for 1995. In 1996, Sida reported about $114 million in population assistance, using a very broad definition of reproductive health. UNFPA’s estimate of Swedish expenditures that year is approximately $58 million, based on its standard and narrower definition of population assistance.

Definitional issues notwithstanding, Sweden remains an important donor to population programs. Sweden ranked seventh in 1996 among donor nations in the level of population funding it provided. Sweden’s population assistance increased 36 percent between 1990 and 1996, with the caveat that the 1996 level reflects a broader range of reproductive health activities. Sweden’s population assistance also rose from 2.1 percent to 2.9 percent as a share of the declining total development aid budget over this period. In addition, Swedish population assistance appears to have increased relative to GNP, rising from $192 per million GNP in 1990 to $242 per million GNP in 1996.

Multilateral Funding:

Over the past decade, Sweden has consistently channeled 40 to 60 percent of its population aid through multilateral organizations. Organizations supported by Sweden include UNFPA, UNAIDS, and the WHO human reproduction research program. However, Sweden’s U.S. dollar contribution to UNFPA fell from $18.4 million in 1993 to $15.1 million in 1997. The Swedish contribution also declined in national currency terms from 1994 and 1997, but then rose slightly in 1998. This small increase, however, is likely to be lost in exchange rate conversion.

Bilateral Funding:

Bilateral funding for population programs has increased from one percent of total population assistance in 1987 to 27 percent in 1996. The proportion of funds going to the multilateral and NGO channels has accordingly decreased during this period. In 1996, Sweden allocated about $15.6 million to population-related activities on a bilateral basis.

Funding for NGOs:

Swedish allocations to NGOs for population activities, including those to IPPF, have fallen during the past decade. In 1987 Sweden channeled fully half of its total population assistance through NGOs; by 1996 it channeled only 32 percent through this channel.

Of the $18.5 million Sweden contributed to NGOs in 1996, $11.4 million went to core support of IPPF, the largest NGO in the population field. The Swedish contribution to IPPF has also declined, amounting to only $7.7 million in 1997–a 32 percent decrease from the previous year. Even in national currency terms, Sweden’s kroner contribution to IPPF has fallen 20 percent between 1988 and 1997. Sida recently completed the first phase of an evaluation of IPPF which acknowledges the strong congruence between the goals of IPPF’s Vision 2000 strategic plan and Sida’s sexual and reproductive health strategy. The evaluation recommends that Sweden continue support to IPPF, and that the Federation develop systems for cost recovery at many different levels of the organization.

In 1995 and 1996, Sida also supported the International Council on Management of Population Programs, the International Women’s Health Coalition, the Population Council, the Swedish Association for Sexual Education and various other Swedish nongovernmental institutions working in the sexual and reproductive health and rights field.

4 Program Priorities

Geographic Priorities:

Sub-Saharan African countries receive the majority of Swedish bilateral aid in the sexual and reproductive health sector. In 1995-96, Sweden funded bilateral programs in Angola, Ethiopia, Kenya, Uganda, Zambia and Zimbabwe. In Asia, Bangladesh is the largest single recipient of Swedish reproductive health aid. Sweden also funds smaller initiatives in Nicaragua and region-wide activities in Central America.

Areas of Program Emphasis:

Swedish aid officials describe their health sector policy as "standing on two legs": health sector support and reform, and reproductive health and rights. Program priorities in the latter area include human rights and gender equality, maternal health and newborn care, fertility regulation, abortion, HIV/AIDS, adolescent health, female genital mutilation, discrimination, violence and abuse. Sweden is notable among donors in its commitment to expanding the availability of medically safe termination of pregnancy (including menstrual regulation), improving access to quality post-abortion care and supporting the liberalization of abortion laws.

Sweden has also made adolescent reproductive health a high priority. Sida’s adolescent programming focuses on sexual and reproductive health education for in-school and out-of-school youth; counseling and provision of contraceptives and STD services through youth clinics; sexual health education through peer counseling and youth clubs; and advocacy with policy makers on adolescents’ rights to information and reproductive health care.

This broad formulation of sexual and reproductive health and rights makes it difficult for Sweden to report on its population programming according to the definitions developed by UNFPA. According to Sida, sexual and reproductive health and rights components are integrated in broad health support projects in some recipient countries, such as Zambia, Vietnam and Uganda. Moreover, the new sector-wide approach to program implementation–where Swedish support is pooled with funds from other donors and from national governments–makes it virtually impossible to account for financial allocations specifically for population-related activities.

5 Technical Capacity

Staffing:

A small cadre of technical staff manage multilateral and bilateral population programming efforts within the Swedish aid administration. One staff-person in the Ministry of Foreign Affairs is responsible for Swedish relations with UNFPA and other multilateral organizations. Within Sida, 10 professional staff have sexual and reproductive health programs within their country portfolios; of these, 4 have special responsibility for policy development and support for sexual and reproductive health and rights and HIV/AIDS.

Technical Expertise of Collaborating Institutions:

Sida collaborates with many Swedish institutions in its bilateral sexual and reproductive health and rights programs. The Karolinska Institute– a world-famous medical research institution–and population centers at the Lund and Uppsala universities are often partners in bilateral program implementation. The Swedish IPPF affiliate (RFSU) and several private development consulting firms and individual experts also assist in the planning, monitoring and evaluation of bilateral and multilateral sexual and reproductive health and rights programs, including those relating to HIV/AIDS.