UNITED STATES

VITAL STATISTICS
1996 population size	269.4 million
Total Official Development Assistance (ODA), 1996	$9,377 million
ODA as a percentage of GNP, 1996	0.12%
Total population assistance, 1996	$637.7 million
Population assistance as percentage of ODA, 1996	6.80%
Population assistance per $US million GNP, 1996	$84

POPULATION AND REPRODUCTIVE HEALTH ASSISTANCE OVERALL ASSESSMENT

The U.S. foreign aid program has faced many challenges in recent years. Funding for overall foreign aid has declined, and the United States now ranks last among donor countries in the proportion of national wealth devoted to development aid. The U.S. bilateral aid agency (USAID) has undergone major restructuring, including reductions in staff and the number of overseas field missions.

The U.S. population assistance effort still leads the way among donor nations. The United States provides the largest population assistance contribution of any donor nation, and also devotes the largest share of its development aid budget to population assistance. U.S. population assistance funds flow primarily through the bilateral and NGO channels; U.S. contributions to multilateral organizations remain relatively small. While the U.S. population assistance program continues to maintain a strong focus on family planning, it is moving towards a more integrated approach to reproductive health programming. With over 30 years of experience in the field, USAID also has the greatest population program expertise of any donor, supplementing a substantial staff of in-house specialists with an extensive network of private and public cooperating agencies.

However, recent political attacks have undermined the U.S. population assistance program and its contribution to achievement of the Cairo conference goals. Severe cuts in population assistance funds and restrictions on their disbursement have constrained the U.S. population assistance effort. Moreover, the 1996 level of U.S. population assistance is only one-third of its "fair share" (relative to the size of its economy) of the year 2000 financial target agreed on at the ICPD. No other donor nation has further to go in absolute terms to bridge this gap.

1 Development Assistance: Policy and Funding

The United States has ranked last among donor countries in recent years in overall aid relative to national wealth (annual GNP). In 1997, it gave only $765 in foreign aid for every million dollars of GNP. In terms of total aid volume, the United States ranks third after Japan and France as a donor nation, providing $6.2 billion in development assistance in 1997 compared with $9.4 billion for Japan and $6.3 billion for France. This level of aid is almost half what the United States gave in 1992, when foreign assistance levels peaked at $11.7 billion, and $3.2 billion less than in 1996. Part of the decline in aid in 1997 reflects that Israel is no longer classified as a developing country; aid in 1996 included $2.2 billion for Israel.

The declining U.S. aid budget largely reflects efforts to reduce government spending and taxes, refocus on domestic issues, and promote international trade as an alternative to development aid. Diminishing aid is also an outcome related to the growing power of conservative Republicans in the U.S. Congress.

Polls suggest Americans are generally supportive of U.S. global involvement and foreign aid despite the low priority attached to foreign aid by their elected representatives. Public knowledge of U.S. development assistance efforts remains limited, however. Many Americans believe foreign aid constitutes a much larger share of the federal budget than the less than one percent it currently receives.

The U.S. foreign aid budget includes development assistance as well as funds for key political allies. The Middle East (26.4 percent), sub-Saharan Africa (21.6 percent) and North and Central America (15.1 percent) received the largest share of development assistance in 1996. The United States allocates approximately half of all development assistance funds to lower income countries. Education, health and population, emergency relief, and food aid programs receive the largest shares of aid resources.

The U.S. Agency for International Development (USAID), the official bilateral aid agency, disburses three-quarters of U.S. foreign assistance. The Department of State administers most U.S. contributions to multilateral institutions, which have accounted for about one-quarter of total official development assistance in recent years.

USAID has undergone a major restructuring effort over the last few years, accompanied by a decrease in staff and the closing of several overseas offices. In addition, legislation passed in late 1998 gives the State Department closer oversight of USAID. The full implications for the U.S. foreign aid program are still unclear.

2 The Policy Environment for International Population Assistance

The United States has historically been one of the strongest supporters of international population assistance. The U.S. government established one of the first international population assistance programs in 1965 and helped to create UNFPA a few years later. For much of its history, the program enjoyed strong bi-partisan support in Congress and the executive branch, reflecting a consensus that rapid population growth was a serious global problem eroding economic and social progress in developing countries. This climate changed in the 1980s during the Reagan and Bush administrations, when anti-abortion groups sought to link international family planning effo rts to the domestic politics of abortion. (In fact, a law in effect since 1973 prohibits the use of U.S. population assistance funds for abortion services.) Despite these political attacks, congressional support remained strong and population assistance funding increased during this period.

In recent years, a small but politically powerful social conservative movement has systematically sought to undermine U.S. government funding for both domestic and international family planning programs. These groups, which have in common a desire to end abortion both in the United States and overseas, have succeeded in imposing funding cuts on U.S. population assistance. Yet polls suggest the vast majority of Americans support public funding for these programs. A broad coalition of NGOs working in reproductive health, development, and the environment are strong advocates for population assistance, and have lobbied the Congress to prevent deeper cuts in funds.

The current administration and Congress have repeatedly been at odds over U.S. reproductive health policy and funding. The Clinton administration is extremely supportive of international population assistance, and took a leadership role at the Cairo conference. Since then, the president has strongly resisted efforts by the Congress to impose new policy restrictions on population assistance funds. Within the Congress, the Senate remains narrowly supportive of international family planning assistance. On the other hand, the House of Representatives has repeatedly voted to deny U.S. family planning funds to foreign organizations if they use other, non-U.S. funds to provide legal abortion services or participate in policy debates over abortion in their own countries. This policy, however, has not been enacted into law. Despite these controversies, the United States remains the largest contributor to international population programs, and still provides almost half of all donor contributions.

3 Trends in Funding for Population Assistance

Overall funding levels:

Funding cuts and restrictions imposed by the Congress beginning in 1996 have effectively reduced USAID’s budget for population assistance. Between 1993 and 1995, high-level political support together with the momentum from the Cairo conference led to dramatic increases in population assistance budgets. Funds approved by Congress for international population assistance peaked at more than $583 million for U.S. fiscal year 1995. However, in 1996, the Congress drastically reduced funding to $379 million; funding increased slightly above this level to $410 million in 1997, then fell slightly to $405 million in 1998.

USAID reported spending $440 million in 1996 and $455 million in 1997 on population and family planning activities, excluding HIV/AIDS and safe motherhood programs. These actual expenditures are higher than recent budgets approved by Congress because they largely reflect funds approved in prior years. If HIV/AIDS and maternal health activities are included, USAID spent $667 million in 1995 and $638 million in 1996 on population and reproductive health more broadly defined. Despite these impressive figures, the U.S. still falls short of its fair share of donor resources committed to at Cairo, based on its relative wealth among donors. Given its huge economy, the United States would need to increase overall population assistance to over $1.9 billion to reach its fair share of donor contributions in the year 2000.

Despite recent cuts in family planning funds, the United States contributes a larger share of its development aid budget to population and reproductive health assistance than any other donor nation. In 1996, nearly seven percent of official development assistance went to population assistance, broadly defined.

Multilateral Funding:

Unlike other large donors, the United States contributes a small proportion of its population assistance through multilateral channels. In 1996, U.S. multilateral contributions amounted to $45 million, or just seven percent of total population assistance. In contrast, the Netherlands channeled 78 percent or $87 million through multilateral organizations.

In 1993, President Clinton restored the U.S. contribution to UNFPA, which had been withheld since 1986 owing to controversies relating to UNFPA’s assistance to China. However, the United States ranked as only the sixth largest donor to UNFPA in 1996, with a contribution of $23 million. U.S. foreign aid legislation for 1999 once again eliminates the U.S. contribution to UNFPA because UNFPA has initiated a new program in China. The withholding of U.S. funds undermines the potential for the United States to play a leadership role on UNFPA’s Executive Board, and also reduces the availability of funds to other developing countries in need of UNFPA assistance.

The United States is a global leader in the fight against HIV/AIDS. Contributions to UNAIDS reached $17.6 million in both 1996 and 1997, nearly one-quarter of its budget. In addition, the United States provided $4 million in 1997 to the WHO human reproduction research program, an international leader in contraceptive research and development.

Bilateral Funding:

Despite recent budget cuts, the United States remains the largest bilateral donor in the population field. Currently, nearly 70 countries receive USAID population and reproductive health assistance. USAID administers direct bilateral population assistance to priority developing countries primarily through its four regional bureaus and its overseas field missions. Thirty-seven percent of total population assistance, approximately $236 million, flowed through the bilateral channel in 1996. The proportion of population aid channeled bilaterally has fluctuated between 54 percent in 1991 and 32 percent in 1993.

Funding for NGOs:

NGOs represent an important channel for U.S. population assistance. The Office of Population at USAID headquarters in Washington, D.C., administers U.S. financial support to a vast network of NGOs known as USAID cooperating agencies. In 1997, USAID channeled $229 million, or 50 percent of all population expenditures, through the Office of Population.

U.S. support to IPPF, the major international NGO in the reproductive health field, was terminated in 1985 by the Reagan administration. The U.S. contribution was restored in 1993 by President Clinton, but has remained at a relatively low and declining level. The United States provided $5.0 million annually in unrestricted funding to IPPF in 1996 and 1997, a 45 percent decrease from 1995 levels. In addition, the United States contributes to IPPF through contraceptive commodity donations and direct funding agreements between USAID field missions, cooperating agencies and local family planning associations.

4 Program Priorities

Geographic Priorities:

Although USAID supports population activities in 69 countries, about 15 countries receive the bulk of program funds. These countries generally have the greatest need for assistance, or have a long-standing cooperative relationship with USAID. The Asia/Near East region received $155 million or just over a third of all population funds in 1997, while Africa received $126 million or 28 percent of the total. Bangladesh, the Philippines, Kenya and India were the largest recipients of U.S. population assistance from 1993 through 1997.

Areas of Program Emphasis:

Family planning remains the cornerstone of USAID’s efforts in reproductive health. Early in the Clinton administration and prior to the Cairo conference, USAID announced a new population, health and nutrition strategy that aims to stabilize global population and improve human health. The new strategy emphasizes the reproductive health needs of women and adolescents and reinforces the lead role of family planning within the population, health and nutrition sector.

Because of its long history in family planning assistance, USAID holds a comparative advantage over other donors in this area. USAID support for family planning initiatives encompasses service delivery, the supply of contraceptive commodities, contraceptive social marketing and other strategies for expanding private sector involvement in family planning. Delivery of family planning and reproductive health services, which includes technical assistance and training, received the largest share of USAID population expenditures in 1997. In addition, USAID provided nearly $39 million in contraceptive commodities to nearly 80 developing countries.

USAID also supports a range of population and reproductive health related research activities, including biomedical studies, development of new contraceptive technologies, demographic surveys, social science research into gender issues and service-delivery research. The Demographic and Health Surveys supported by USAID are nationally representative sample surveys that have been especially important in documenting unmet need for family planning and tracking trends in contraceptive use, child health and fertility in developing countries. In the last five years, these surveys have expanded to include indicators relating to male use of family planning, maternal mortality and HIV/AIDS.

Over the last few years, USAID began to reshape its population and health assistance to support the broad reproductive health approach advocated at the 1994 ICPD. USAID has placed particular emphasis on strengthening programmatic links between family planning and other reproductive health activities. The Cairo conference has also helped spur new initiatives in adolescent health, post-abortion care and integration of family planning services with efforts to prevent AIDS and other sexually transmitted diseases. In addition, USAID has increasingly worked in technical and financial partnership with other donor agencies working in the population and reproductive health field. For example, it has sought to collaborate more closely on population and AIDS activities with Japan through the U.S.-Japan Common Agenda.

In an effort to reduce HIV transmission and the impact of HIV/AIDS in developing countries, USAID has supported various prevention and treatment initiatives. Recent undertakings include a rapidly expanding social marketing program focusing on male and female condoms, products for the diagnosis and treatment of sexually transmitted infections, as well as public health messages. USAID also continues its active support of maternal health and nutrition initiatives designed to improve pregnancy outcomes and child health. Within its broader goal of increasing the social, economic and health status of women, USAID has recently embarked on initiatives in the areas of micro-enterprise, legal and political rights, and education, including a five-year project to increase girls’ educational opportunities in twelve countries.

5 Technical Capacity

Staffing:

The technical capacity of the U.S. international population assistance program is unmatched by any other donor. With technical staff based both at headquarters and overseas, USAID has a wide base of knowledge and experience in the international population field. At USAID headquarters in Washington, D.C., a critical core of over 80 experts has experience in population programs.

Within USAID, there is an increasing trend towards integrated management of population and health activities. The Center for Population, Health and Nutrition (PHN), within the Bureau for Global Programs, Field Support and Research at USAID headquarters, was created in 1994. The Center brings together the Office of Population, Office of Health and Nutrition, and Office of Field and Program Support under unified management. Staff from all three offices increasingly work together on jointly-funded projects.

USAID’s field presence is also a unique strength of its population assistance effort. The agency has nearly 100 expatriate and local population and health staff in nearly 50 of its 85 country offices. USAID’s ability to provide technical and managerial oversight for its assistance through a professional corps of field-based population officers has contributed to effective implementation of bilateral population projects, as well as to the success of country programs.

Due to the overall decline of agency resources, USAID has seen a substantial reduction in the number of permanent population and health staff. Meanwhile, management burdens on technical staff are increasing; expert population and health staff manage roughly double the volume of funds compared to a decade ago. The agency is now moving to recruit new staff in the population and health fields.

Technical Expertise of Collaborating Institutions:

Adding strength to USAID staff is the established network of U.S.-based cooperating agencies which implement USAID-funded projects. These cooperating agencies include over 30 universities, private companies, research and educational organizations, other U.S. government agencies, international organizations, and nonprofit organizations with the expertise and staff to fulfill broad contractual mandates. The Office of Population enters into agreements with these institutions to provide technical assistance to national governments and NGOs in developing countries. Many of these agencies have expertise in specialized areas such as population policy development, family planning service delivery, communications, training or evaluation, helping to broaden USAID’s technical capacity.