The Future of U.S. Government Involvement & Funding for Family Planning & Reproductive Health Programs in the Evolving U.S. Aid Architecture

by Craig Lasher

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 ‘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

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 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.