While the past decades have seen a foreign aid field dominated by the world’s wealthy countries who are members of the Organisation for Economic Co-operation and Development (OECD) and its Development Assistance Committee (DAC),[1] a new form a donorship has emerged, or more accurately, re-emerged. Aid funding from prosperous, yet still developing countries to other developing countries has drawn international attention, much of it from a critical perspective. A 2007 article in Foreign Policy labeled aid from China, Venezuela, and Saudi Arabia as both “generous” and “toxic,”¹ while a recent cover of the Economist labeled China “The New Colonialists.”² However, an increase in global aid to the poorest countries, delivered with fresh perspectives and an intensified spirit of South-South cooperation has many potential benefits.

While some donors and international observers criticize non-DAC aid for being overly influenced by economic or political interests, these and other important concerns apply to many DAC countries as well. A major shortcoming of the DAC donor community is lack of commitment to family planning and reproductive health. Nearly all donors fall short of the financial commitments made at the 1994 International Conference on Population and Development in Cairo, where they pledged funding for family planning and reproductive health. Reproductive health care encompasses a range of issues, including family planning; STI and HIV prevention, care and treatment; and maternal and child health. An intense focus on HIV in the donor community has occurred alongside a significant decline in support for the other facets of reproductive health. The U.S., which is by far the largest provider of funds for family planning and reproductive health, has significantly cut funding for family planning, child survival, and maternal health, while dramatically increasing its funding for HIV/AIDS, and when adjusted for inflation, U.S. bilateral funding for family planning and reproductive health in 2007 was 41 percent less than in 1995.³ With such significant shortfalls, and such a great need for services, engaging new donors is an important opportunity.

This commentary will examine the current debate on the rise of “new” bilateral donors, the perceived threats to international aid effectiveness efforts, and possible benefits for poverty reduction and economic development, focusing on two major non-DAC donors, India and China. Finally, the commentary will offer recommendations on increasing the effectiveness of aid in these countries, and given the shortfalls in funding from DAC donors for family planning and reproductive health, consider how funds from these “new” donors can help to support family planning and reproductive health in the developing world.

The Shape of International Aid

From the mid-1990s until the present, DAC countries have contributed at least 95 percent of overall international aid, with an average of 23 percent given through multilateral institutions.^{4 5}  The DAC acts as a forum for these countries in their roles as bilateral donors, and is meant to facilitate donor cooperation and sharing of best practices, as well as increasing aid effectiveness.⁶ DAC countries have developed the dominant definitions, guidelines, and tracking mechanisms for development assistance, including efforts to increase aid harmonization. However, the DAC member states have by no means been the only sources of bilateral aid, and have not always had their current level of dominance.

Prior to the 1990s, the donor field was significantly more diverse. The Soviet Union and Central European countries were active aid donors until the collapse of the USSR, when many became aid recipients themselves. Persian Gulf countries have administered large aid programs for decades, and at their height in 1978, Organization of the Petroleum Exporting Countries (OPEC) member contributions comprised 30 percent of all international aid. Further, many developing countries have contributed aid and technical assistance through a long history of South-South cooperation.⁷ For example, many Asian countries have provided development and humanitarian aid, particularly for their neighbors (e.g., India has long been a donor to neighboring Nepal and Bhutan), and technical assistance and training is commonly exchanged between developing countries.⁸ Many non-DAC donors participated in the Non-Aligned Movement in the 1950s which emphasized respect for sovereignty and non-interference, and are members of the G-77, which has criticized richer nations for using humanitarian assistance to further political ends.⁹ However, as some of these countries develop their own aid programs, many are facing the same criticisms.

Much like DAC members, non-DAC donors are a diverse group, with different geographical and thematic foci of aid giving, often reflecting political and economic interests or historical ties. The former Soviet Union provided aid to other communist nations (many of which, including Vietnam and Angola, still receive funding from former Soviet donor countries), frequently in the form of training and scholarships. Gulf States previously supported anti-Soviet countries and now focus on aid to predominantly Muslim developing countries in their own region and Africa. Giving is also influenced by security concerns, as China and South Korea give large amounts of aid to North Korea, Central European states have contributed to Balkan nations to support stability, and India has given significant aid to Nepal, Bangladesh, and Afghanistan to support regional stability and counter the influence of neighboring Pakistan.¹⁰ Venezuela is an important donor in the Caribbean and in some Latin American countries, while Brazil is active in the Lusophone commonwealth, including funding water programs in Angola.¹¹ The increased interest in foreign aid among non-DAC donors is particularly apparent in response to humanitarian crises: 16 countries pledged support for the Bosnian humanitarian crisis in 1994, while 92 pledged support to those affected by the Asian tsunami in 2005.¹² Just a few weeks after Tropical Cyclone Nargis struck Myanmar in May 2008, pledges of funding, in-kind donations, and response teams, came in from 22 non-DAC countries—the majority from Asia, but also from Eastern Europe, Latin America, and the Middle East.¹³

In contrast, there is less emphasis on social development in non-DAC donorship, and very little evidence of significant non-DAC bilateral or multilateral aid for family planning and reproductive health. Turkey is an exception, providing $4.26 million in 2006 for population and reproductive health activities, comprising 1.6 percent of their social infrastructure and services budget, and 0.67 percent of its overall bilateral assistance.¹⁴ South Korea—whose total 2007 official development aid (ODA) was US$680 million– provided training for personnel from various regions in family planning and reproductive health, and is implementing an adolescent pregnancy prevention program in the Dominican Republic, with total support for population and family planning at $541,000 from 2003 to 2006.^{15 16} 

Endnotes may be found on a separate page, located in the left navigation.

Aid volumes

Assessing the non-DAC donor landscape is difficult, although it is certain that the contribution of non-DAC donors remains relatively low in comparison to that of DAC members, who contributed $106.8 billion in ODA in 2005.¹⁷ DAC countries are required to have aid volumes either over US$100 million, or an ODA to GNI ratio over 20 percent, as well as to provide annual required ODA statistics to the DAC, among other requirements. Some donors that are not members of the DAC still follow specific tracking guidelines set by the DAC and report their aid to the DAC’s tracking mechanism, which shows that in 2005, 17 non-DAC countries reported $3.2 billion in ODA. Non-DAC countries that are members of the OECD, such as South Korea – which is preparing to join the DAC in 2010 – Turkey, and the Czech Republic, contributed $1.9 billion, and Arab states gave $0.7 billion . Many non-DAC donors operate very differently from the aid classification and reporting guidelines of the DAC, as well as other guidelines required for DAC membership, including China and India, some of the most important non-DAC donors.¹⁸ This leads to conflicting estimates of these countries’ giving. Manning estimates that China provides $2 billion per year, and India provides $1 billion, while the EU estimates that China contributes $5 billion in development assistance per year, and India contributes $100 million per year. Another observer considers these figures too conservative, and estimates India’s aid at $300 million annually. ^{19 20 21}  The structure of foreign aid programs in many non-DAC countries further complicates tracking. Responsibilities for foreign aid are spread throughout various ministries, making it difficult to track expenditures, and many provide in-kind donations, which vary in valuation.²²

While aid of non-DAC countries is unlikely to surpass that of DAC donors and development banks in the foreseeable future,²³ non-DAC funding is likely to continue to rise for multiple reasons. New EU members that are not yet members of the DAC are increasing ODA to meet EU membership targets (they are attempting to reach targets of ODA as 0.17% of GNI by 2010, and 0.33% by 2015, although the size of their economies make their absolute contribution relatively small). Some non-DAC countries with large ODA programs, such as South Korea and Turkey, are expanding their programs further, as are some states with smaller programs. Finally, India and China, with their booming economies, are expanding their aid programs in a professed spirit of South-South cooperation, as well as to raise their international profile and expand access to natural resources and new markets for their goods.²⁴ Further, the increasing array of donors provides new funding opportunities for recipient countries and more leverage with traditional DAC donors and development banks. Recipients also find some non-DAC donors appealing because they do not place the same conditions on aid as do DAC members or large development banks.²⁵

“New” donors and the push for aid effectiveness

In 2005 the international community endorsed the Paris Declaration on Aid Effectiveness, which galvanized the push for increased country ownership, aid alignment, and donor harmonization.²⁶ As non-DAC donors—including China and India—increase their international aid, some critics are concerned that the proliferation of donors will undermine aid effectiveness, labor conditions, and environmental standards, and fragment efforts to harmonize donor practices.²⁷

The DAC sets standards that are supposed to increase the positive impacts of donor aid from member countries. For example, DAC discourages aid that is tied to goods and services from the donor country. DAC donors are supposed to place positive conditions on aid, including requirements for good governance, human rights and transparency, as well as environmental, labor, health standards.²⁸ Further, all DAC members endorsed the Paris Declaration principles, including being increasingly guided by recipient strategies and priorities, and committing to higher levels of collaborations with the partner country and other donors.²⁹

These donor guidelines are highly criticized and are often ignored in practice. Recent studies of the Paris Declaration have found that the new guidelines exacerbate the power imbalance between donors and recipient countries and place greater reporting burdens on recipients, both of which undermine the goal of country ownership espoused in the Declaration.³⁰ Furthermore, some argue that the Paris Declaration's emphasis on recipient country ownership is undermined by threats to sovereignty implicit in conditional aid extended by DAC members and multilaterals.³¹ However, these standards are important because civil society groups and recipient country governments can hold DAC donors accountable to their positive aspects. And DAC reporting guidelines (discussed in the previous section) increase donor transparency and accountability.

While most non-DAC donor countries are officially listed as adhering to the Paris Declaration, supporting improved donor practices in their role as aid recipients, many do not follow these guidelines as donors. In Africa, for example, China offers substantial support in exchange for access to natural resources, contracts, and ending diplomatic relations with Taiwan, without conditions related to human rights and governance in the recipient countries.³² This has led to fears among DAC countries that incentives to improve governance and human rights will be undermined by these new sources of funding. Further, some non-DAC donors provide “soft,” or low-interest loans to other countries, leading to concerns that formerly Heavily Indebted Poor Countries (HIPCs) that benefitted from debt relief will again borrow at unsustainable levels. ³³ 

Endnotes may be found on a separate page, located in the left navigation.

Country Study: India

As an architect of the non-aligned movement in the 1950s, which emphasized sovereignty, non-interference, and South-South cooperation, India has been active in aid donorship and knowledge transfer since the 1950s, particularly in the South Asia region. However, in the 2000s, India has shifted its foreign aid policies, both in terms of its role as a donor to other countries and how it receives aid from bilateral partners. While India’s foreign aid funding is relatively small, it is increasingly tied to a package of economic and diplomatic advantages that can prove very valuable to other developing and transitional countries, as well as beneficial to India’s own booming economy, just as in DAC countries.
 
Traditionally, India’s foreign aid has focused on neighboring countries in South Asia, often in support of regional stability and countering the influence of neighboring Pakistan. The Indian Technical and Economic Cooperation (ITEC) scheme was initiated in 1964 and has provided training programs for 154 countries, focusing on South Asia and African members of the Commonwealth of Nations. The program focuses on training, project related activities, study tours, and provision of Indian experts. The program budget is $11 million, which provides training for 3,000 people each year. India also provides skilled personnel to multilateral organizations, as well as technical experts in various areas, while 55,000 Indians have worked as UN Peacekeepers.³⁴ India has also funded infrastructure projects in neighboring countries,³⁵ has been a contributor to the UN system's food program, and hosts a large number of refugees from Sri Lanka, Tibet, Bhutan, and Bangladesh. India’s aid is predominantly bilateral, including a mix of low-interest loans and grants, and while it is more open about its aid than China, the lack of reporting standards make aid flows difficult to track.^{36 37} 

In 2003, India’s aid program entered a new phase as the finance minister outlined a new approach to foreign aid, explicitly in line with its own economic development and international profile. The India Development Initiative changed India’s role as an aid donor and recipient, announcing that India would no longer accept tied aid, and that it would accept bilateral aid from only five countries­ – the U.K., U.S., Russia, Germany, and Japan – and the European Union. Notably, these were not the five largest donors, as the Netherlands provided significantly more funding to India than the U.S. or the E.U. India encouraged the Netherlands and other former donors to provide assistance to NGOs, or channel their funding through multilateral organizations. The basis of selecting the five bilateral countries is unclear, but the Indian government seems to be more willing to accept aid from countries on the UN Security Council, and thus important international allies, and less likely to accept aid from countries that have scaled back aid or voiced significant disapproval over Indian affairs, such as the 1998 nuclear tests and the handling of communal violence in Gujarat in 2002.³⁸ India’s new policies as an aid recipient led to a much publicized refusal of bilateral aid in the wake of the 2004 tsunami, in which India provided aid to neighboring countries, such as the Maldives and Sri Lanka, despite its own heavy losses.³⁹ In addition, in 2003 the Development Initiative announced that India would pay off loans to all but four countries, would cancel the debt owed India by several heavily indebted poor countries in Africa and Latin America (including Ghana, Mozambique, Tanzania, Uganda, Zambia, Guyana, and Nicaragua), and would increase grants and project assistance to developing countries in South Asia and Africa.⁴⁰
 
These changes came in the context of increasingly large foreign reserves in India, as well as increasing requirements for new markets, raw materials, and energy in the expanding economy. India is highlighting development partnerships with countries with oil, raw materials, or with large Indian Diaspora populations, although it still focuses mainly on countries in the South Asian region. Bhutan has received significant ODA from India since the 1960s. Because of its status as an important buffer state between India and China, India has supported hydroelectric power projects in Bhutan that now provide energy for India as well. India has provided military, economic and development aid to Nepal, and is significantly aiding Afghan reconstruction."⁴¹

As mentioned above, India does not report its development activities to the DAC, and does not classify and track funds in line with DAC standards, making it difficult to quantify aid volumes. Lines are blurred between development aid and foreign policy and trade interest. By one estimate, Indian aid amounted to $300 million in 2006, but because India couches its aid in terms of investment and partnership rather than casting itself as a donor, it is inadequate to look at India's ODA flows apart from the complete package of economic and political assistance to other developing countries. This report notes that “India is only a donor when it is also an investor, trade partner, or political ally, or can become one,”⁴² a phenomenon that is not unique to India and applies to many more “traditional” donors as well. While this broader relationship can be positive for partner countries, some components of Indian aid have potential negative effects. For example, India refuses tied aid from other sources, but many of the grants and soft loans extended to other countries are tied to Indian goods and services.⁴³ Further, its emphasis on non-interference means that Indian aid is not conditioned on good governance or human rights records.⁴⁴

Endnotes may be found on a separate page, located in the left navigation.

Country study: China

China’s aid program is somewhat similar to India’s in terms of its long history of donorship and technical assistance, as well as ties between its foreign policy and its economic expansion and the subsequent need for new markets, energy, and natural resources. However, China’s investment and aid to other developing countries is much larger and more difficult to track than India’s, as China does not formally release its aid figures, let alone report them to the DAC. In 2005, Premier Wen Jiabao said that China had expended $3 billion over the preceding 5 years. The U.S. treasury estimated that China gives $500 million annually to North Korea while analysis of press reports suggests that it provides $888.9 million to Asian countries, and $800 million annually in grants and loans to Africa.⁴⁵ Its enormous foreign reserves and highly publicized relationship to the Sudanese government ­– problematic for public relations in the run up to the Beijing Olympics­ – have drawn international attention and criticism. A recent cover story of The Economist described China as “The New Colonialists,” a label China increasingly battles. However, while many aspects of China’s aid are deeply problematic, recipient countries perceive many benefits from partnership with a country with a track record of rapid economic expansion and monumental poverty reduction, and with a seat on the UN Security Council.⁴⁶

Like India, China has a longstanding policy of aid to other developing countries. China provided active support to independence movements in Africa in the mid-20th century, and provided various kinds of support for post-colonial reconstruction, including both technical training and capital intensive projects to build infrastructure.⁴⁷ China's articulation of an aid philosophy began in the 1950s, with support to India and the building of the Zambia-Tanzania railway. In 1964, then-Prime Minister Zhou Enlai articulated the principles of noninterference in the internal affairs of other countries, and equal relations based on mutual benefit, solidarity and cooperation among developing countries, which continue to inform Chinese donorship, while Mao Zedong urged that as China developed, it should increase aid levels to help other countries do the same.^{48 49}  Historically, Chinese aid projects focused on building self-reliance, such as training of foreign students in Chinese Universities, and agricultural and technical assistance, which were characterized by interest free loans and investment in projects that could be built quickly, including large stadiums in developing country cities. These programs were generally tied to use of Chinese construction companies and workers, and also had the stipulation of gaining support for the One-China Policy by requiring recipient countries to end their diplomatic relations with Taiwan.⁵⁰ Chinese foreign aid was shaped further by geopolitical struggles with the US in the 1950s and 60s, and with the USSR from the late 1960s to early 1980s. Aid rose as high as 6 percent of public expenditure, but was scaled back in the early 1980s, when China began receiving large amounts of ODA from other countries and focused on its own economic growth.⁵¹

China’s foreign aid program became more active again in the 1990s, contributing to an International Monetary Fund (IMF)-led relief effort for Indonesia in 1998 after the Asian Financial Crisis, contributing to major humanitarian aid for Afghan reconstruction in 2003, and contributing $63 million in bilateral tsunami relief in 2006.^{52 53} Most Chinese aid has been bilateral in nature (although it has included contributions to UN agencies, including the World Food Program).⁵⁴ The country’s aid structure is split between multiple ministries, including the Ministries of Foreign Affairs, Finance, and Commerce, and a regulatory framework for its aid has yet to be developed.⁵⁵ In contrast to policies earlier in the 20th century, Chinese aid now commonly takes the form of preferential loans, rather than the interest-free loans provided in the past, and there has been an increase in venture capital and business-to-business cooperation.⁵⁶ China has increased funding for large infrastructure projects. While loans are generally tied to the purchase of Chinese goods and services, there are usually no other conditions, such as environmental or social, attached.⁵⁷ China operates largely outside the DAC international donor community, but has increased its participation, including contributing to a DAC peer review of the U.K.’s Department for International Development (DFID).⁵⁸

While research found scant consideration of family planning and reproductive health in China’s assistance, its aid program has long been involved in health sector work. China has been sending medical teams to other countries and building health centers since the mid-20th century. Twenty thousand Chinese doctors and nurses have been sent to Africa since 1963, and currently 1,100 are active on the continent.⁵⁹ Then-premier Hu Jintao’s 2005 pledge to increase aid also included plans to build and improve health centers, and China has pledged to provide anti-malarial drugs, as well as training for local health staff.^{60 61}  More recently, China donated $500,000 to Somalia through the World Health Organization (WHO) to expand access to health services and supplies to internally displaced persons.⁶²

Africa, Oil, and Chinese Aid

While China has traditionally offered large amounts of aid to Asian countries, ­ both the Chinese government and Chinese businesses have become increasingly involved in Africa over the last decade. Between 1994 and 2006, the China ExIm bank gave 259 loans to African countries, concentrating on Angola, Nigeria, Mozambique, Sudan and Zimbabwe, mostly for large infrastructure projects, including energy and mineral extraction as well as multi-sector transport, telecom, and water projects.⁶³ In 2003, Wen Jiabao announced debt relief of $1.3 billion for 31 African countries and outlined plans for increased China-Africa cooperation, aid, and investment.⁶⁴ In January 2006, the Chinese Ministry of Foreign Affairs stated that its contributions to Africa would be based on principles of peaceful coexistence, "sincerity, equality and mutual benefit, solidarity and common development."⁶⁵ China announced that it would double aid to Africa, with a package including $5 billion in loans and grants, $5 billion for a China-Africa development fund, significant debt forgiveness, training of 15,000 Africans and increased scholarships for African students to study in China.⁶⁶ China purports to view African countries as partners for investment and not solely as recipients of aid, and does not criticize countries for internal human rights issues, nor refuse to partner with countries on that basis.⁶⁷

China’s intensified engagement in Africa has been driven by the rapid growth of the Chinese economy and its need for energy. The world's second largest energy consumer, China imports 25 percent of its oil from Africa, and is actively prospecting for oil in several African countries.⁶⁸ Two-way trade with Africa totaled more than $50 billion in 2006, with oil imports by China accounting for 60 percent of this trade; more than 800 Chinese companies are doing business in about 50 African countries.^{69 70} In return, however, China is accused of flooding African markets with inexpensive Chinese-made goods that are damaging to fragile African industries, such as the textile sector. China has taken some measures to rectify this, exempting some commodities from tariffs when importing from the 25 poorest African countries. This is a greater problem in countries that are not major oil exporters, and who are seeing huge trade imbalances with China. Further, the Chinese are criticized for using Chinese workers, both in their aid and in the companies working in Africa, when many positions could be filled by African workers, thus helping stimulate local economies.⁷¹ For example, while investing heavily in oil development in Sudan, China has been criticized for importing Chinese labor rather than hiring Sudanese workers.⁷² This imbalance is not unique to China, and is a problem frequently linked with international trade. It is important that all countries, not just China or other emerging donors, implement beneficial trade policies, and not attempt to make up for harmful trade policies with foreign aid.

While increased aid flows are welcomed, many developed and developing country leaders alike are concerned about China’s approach. The country will have to battle perceptions that its trade relationships are neocolonialist, and also defend its relationships with countries with records of corruption or human rights abuses, such as Sudan and Zimbabwe. Lack of restrictions on its aid funding lead some to question whether aid funding is being used correctly, and if its benefits are trickling down past country elites.⁷³ Further, China’s tied aid, such as using Chinese workers to implement construction projects, limits capacity-building in recipient countries. There is also little evidence of the use of benchmarks and evaluation in China’s aid programs.⁷⁴ There are also legitimate concerns that Chinese aid and trade to Africa, mainly exploitation of natural resources, will prop up bad governments and provide funding for ongoing conflicts.⁷⁵ However, China's aid, with its limited conditions, is often quicker, less expensive, and more flexible to local conditions than Western aid. As such, China should be engaged and encouraged to be more open about its work and not be viewed solely as a threat.⁷⁶

Endnotes may be found on a separate page, located in the left navigation.

Recommendations and Implications for Reproductive Health

There are many potential benefits to having greater flows of funding provided by new donors, who bring different perspectives and experience from their own economic development. However, there is little evidence that emerging donor aid is currently helping to bolster lagging population funding. While funding for family planning and reproductive health is already difficult to track due to changing aid mechanisms, the most comprehensive source of data– UNFPA, UNAIDS, and NIDI’s Resource Flows Project– “does not include...funds contributed by developing countries to be expended in other developing countries.”⁷⁷ Many of the emerging donors have particularly interesting experience with voluntary family planning programs, as declines in fertility rates occurred alongside their economic development. For example, in Thailand, the total fertility rate fell from 3.76 in 1975 to 1.85 today, while per capita GNI grew from $350 in 1975 to $3,050 in 2006.^{78 79} Of course, coercive policies, such as China’s one-child policy, should not be exported. Still, many of the areas under the umbrella of reproductive health could be strengthened through Chinese investment and through lessons learned through the country’s experiences in improving girls’ education and maternal health.

The international community is still developing models of engagement with “new” donors like China and India, which can be used to promote investment in voluntary family planning and reproductive health. Multilateral engagement could take the shape of the World Food Programme’s successful involvement with new donors. They have been particularly successful in engaging non-DAC donors by publicizing their contributions as a way to improve the donor country’s image in the international press and their standing within the UN.⁸⁰ Another potential method is through trilateral exchange, in which a DAC donor, a non-DAC donor, and a recipient country collaborate to develop and implement a program, allowing the countries to pool resources and develop capacity. This has considerable potential for increasing investment in voluntary family planning and reproductive health programs, but a brief by the German Development Institute advises that such an approach is most beneficial for engaging non-DAC donors that have made strides towards DAC standards. In contrast, they urge that countries such as India and China, are better engaged in dialogue surrounding good donorship, including inviting their participation in peer reviews of DAC projects.⁸¹

As with most donors, such efforts must identify the benefits to the donor country for their investment in family planning and reproductive health funding. Multilateral contributions could increase these countries’ international profiles, and investments in voluntary family planning programs in other countries could also counteract negative opinions of their own domestic population programs (although coercive programs do not deserve to be seen in a positive light). It could also counter accusations that emerging donors’ aid programs are purely exploitative and profit driven. Regardless of the methods and motivations, as non-DAC country aid programs are likely to continue to grow and evolve in the coming years, it is important for the sexual and reproductive health community to engage with these donors to increase their funding for family planning and reproductive health programs, to build their capacity to implement programs, to challenge traditional donors to increase their funding, and contribute to improving the lives of women and their families in developing countries around the world.

Endnotes may be found on a separate page, located in the left navigation.
]]> http://www.populationaction.org/Publications/Research_Commentaries/March_2008/Summary.shtml?s_src=RSS 03/25/2008 PST U.S. Policies & Funding 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

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.

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 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 ‘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.]]> http://www.populationaction.org/Publications/Research_Commentaries/July_2007/Summary.shtml?s_src=RSS 07/12/2007 PST International Advocacy, Institutions & Partnerships Country stakeholders – governments, parliamentarians and civil society – have always been challenged by a limited ability to influence decisions made at the international level. With international donors now seeking to move decision-making and ownership to the country level, we have a remarkable opportunity to establish a transparent, participatory and inclusive process. This is particularly critical to the SRHR community which, due to the often controversial nature of the work, requires institutionalized processes as well as strong, well-informed champions, to ensure that its concerns are adequately funded in development strategies.

Population Action International is dedicating a series of research commentaries to the examination of new trends in funding mechanisms for sexual and reproductive health and rights (SRHR). This commentary is the second in the series, and builds on the September 2006 commentary, by exploring one of the key principles now being embraced by the donor community – that of country ownership. The authors do not intend to explore the issue of country ownership in depth here, but rather to identify key areas that could be the focus of new discussions and research within the SRHR community. The concept of country ownership, as outlined in the Paris Declaration on Aid Effectiveness, is cited as a key tenet of aid effectiveness strategies embraced by large donors such as The World Bank in its Poverty Reduction Strategy Paper (PRSP) processes, bilateral donors that are adopting direct budget support, and global funding mechanisms such as the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM).

How is Country Ownership Defined?

Most references to country ownership in the development assistance literature mention the concepts of national leadership, responsibility and participation. For example, the Paris Declaration on Aid Effectiveness of 2005 states that country ownership will be achieved when “partner countries exercise effective leadership over their development policies and strategies.”¹ The World Bank defines country ownership as the existence of “sufficient political support within a country to implement its development strategy.”  It also defines it as “demand driven by the country.”² The Millennium Challenge Account cites as one of its three core values to “place a country in the driver’s seat of its own development.”³ And section 4.1 of The European Consensus on Development, the instrument meant to guide the European Union’s development assistance efforts, indicates that “ownership and partnership” are among its common principles and that “The EU supports the broad participation of all stakeholders in countries’ development and encourages all parts of society to take part.”  (Section 4.3)

Country Ownership is More than Government Ownership

Governments often appear as the de facto targets of country ownership strategies. Civil society⁴ and other non-state actors are mentioned more marginally, in many cases, as stakeholders whose participation is supported and encouraged, but not “required” as an indispensable component of country ownership. However, country ownership cannot be defined only at the government level. Governments change and rarely do they adequately represent the views of the entire citizenship of a nation.   Moreover, there is a large body of literature showing that broader participation and public consultation result in better development policy and programs. Country ownership requires the active participation of non-state stakeholder groups, in particular, as is asserted in the Paris Declaration, civil society and the private sector (and, we would add, parliamentarians):   

“Partner countries commit to: Take the lead in co-ordinating aid at all levels in conjunction with other development resources in dialogue with donors and encouraging the participation of civil society and the private sector.”⁵

The challenge is to ensure that words such as these are effectively translated into action. The concept of country ownership must be moved from being part of a newly agreed policy framework into actual implementation of participatory mechanisms at the country level.

In this context, we suggest the following definition of country ownership: An institutionalized process that allows for the participation, as equal partners, of governments, non-state actors (such as civil society and the private sector), and parliamentarians, in the development, implementation and monitoring of national development plans. 

Making Country Ownership a Reality

Country ownership is critical to the success of new development assistance modalities. In turn, the full involvement and broad participation of civil society, parliamentarians and the private sector is critical to the success of country ownership.

To facilitate the full involvement so critical to country ownership, certain conditions must be present:

1.   A policy framework supportive of Civil Society Organizations (CSOs)

A prerequisite for non governmental organizations (NGOs and other CSOs) to be equal development partners is the existence of a policy framework that recognizes their relevance, role and right to, for example, conduct independent activities (without the pre-approval of the government, including for the receipt of foreign funds); to meet and express opinions; to approve self-governance mechanisms, as well as to engage in advocacy and monitor the work of the government.

2. Existence of  institutional mechanisms for the broad participation of CSOs  in the development, implementation and monitoring of development plans 

Full participation of CSOs in all development processes must be institutionalized. It should not be needs-driven or ad-hoc. Rather, it should take place throughout the entire process, including during the policy development, implementation and monitoring phases. 

Stakeholders themselves cannot be token participants, but must truly reflect the constituents they are intended to represent. For example, civil society representatives at the table must include broader participation than national or international NGOs. CSOs have the responsibility to ensure that local and community-based groups, including representatives of vulnerable and marginalized populations, have a voice. Appropriate mechanisms - such as a transparent election process of representatives - should be in place.

3.  Investment in capacity building

After decades of donor dependency and donor-driven policies, country ownership cannot be expected to be realized without substantial investments in capacity building. All major stakeholders in the development process need to increase their capacity to make country ownership a reality. This paper focuses in particular on the capacity building needs of  country governments, including: government officials and civil servants; Members of Parliament, as part of the legislative branch of the state and the link between the government and the citizens; and civil society, including NGOs and community-based organizations. 

Key capacity building needs include:

· Understanding development assistance mechanisms, in particular country budget, expenditure and reporting processes;

· Developing country-specific performance and results-oriented indicators;

· Engaging in advocacy and watchdog activities (not only with the central government, but also with regional and local authorities);

· Monitoring implementation and setting up accountability mechanisms;

· Strengthening the role and autonomy of parliaments in policy development and monitoring;

· Creating effective and inclusive management structures;

· Developing and engaging in participatory mechanisms and processes at the national and regional levels; and

· Developing alliances and partnerships.

While some are more relevant to certain constituencies than others, all the above needs are applicable to the three groups of stakeholders identified earlier (governments, CSOs, and parliamentarians).

Capacity building cannot be effective without a sustained source of funding from both donors and country governments; the active engagement of recipients (not only as targets but also actors); flexibility to adjust to national and local conditions; and sufficient time to be able to achieve and demonstrate results.

4. Full information and transparency

The provision of relevant, timely and transparent information to all stakeholders about process and progress in a continuous manner is key to their meaningful participation. It remains difficult for NGOs and other non-state actors  to gain access to information during critical periods of decision-making.  Information often arrives too late and incomplete, particularly regarding funding levels, sources and channels.  Commitments to transparency made by donors and aid recipient countries are insufficient if they don’t include the systematic disclosure of financial information to CSOs and the general public.

Shared Accountability and Responsibility

Accountability and responsibility for country ownership is shared by all stakeholders – recipient governments, donors, parliamentarians and civil society. Country ownership cannot be achieved without mechanisms to operationalize and monitor the responsibility of each of these constituencies.

Donor Responsibility

The donor community has designed various policies and procedures to help foster country ownership, such as:

• Changing aid modalities to mechanisms that move decision-making to the country level (for example, PRSPs and direct budget support);
• Formation of country level coordination committees – such as the Global Fund’s Country Coordination Mechanism;
• Building capacity to better enable countries to take leadership of the development process – such as technical assistance to the country in the preparation of strategy documents, and preparation of guidelines for the drafting of those documents or proposals; and
• Encouraging or mandating broad participation in the development of aid strategies – for example, by requesting that strategy formulation processes include consultations with private sector, NGOs, parliamentarians and other stakeholders.

Moreover, donors are responsible for ensuring that the actions they take in each nation do not contradict or render impossible the actual translation of their country ownership policies and procedures. For example, in a report on the Paris Declaration, Britain’s Department for International Development (DFID) noted the following donor actions that can potentially undermine government capacity and country ownership: donor pressure to spend the funding; lack of alignment of donor and government planning cycles; donor overcrowding; donor paperwork requirements; and lack of sustained and long term financial support.⁶

The Country Policy and Institutional Assessment (CPIA) is another example of how donors may promote country ownership with one hand and obstruct it with the other.  The CPIA is a rating used by the World Bank to assess the economic, social, and political performance of borrowing governments. It is based on a set of criteria developed by the bank with very marginal involvement of country governments. The CPIA is also mentioned in the Paris Declaration (in the Alignment 2010 Targets). A good CPIA rating is a condition to access more financing or debt relief and it also plays a key role in the consideration of a PRSP by the donor. However, country governments have no meaningful involvement in the development of the CPIA with the World Bank. They can, at best, comment on the CPIA “as part of a consultation process, not as a negotiation of the rating(s).”

In addition, donors have, through their discussions with country governments and their financial support, a vital role to play in ensuring that CSOs (1) participate as full and equal partners in national development processes and (2) act as effective advocates and government watchdogs.  The same could be said for the unique position that donors hold to promote and support national parliaments that are actively engaged in policy development and monitoring.

Finally, donor governments are responsible for allowing for differences in the manifestation of country ownership in each nation depending on its specific political, economic and governance context. The adoption of certain aid mechanisms can also be tailored to specific levels across the continuum of country ownership, ranging from project support for countries with weak ownership capacity to direct budget support for countries with strong ownership.

Recipient Government Responsibility

As welcomed as it is, country ownership demands an enormous effort from aid recipient countries. Such an effort can not be successful without the financial support of donors (including funds earmarked for capacity building). However, equally important is the level of commitment of recipient governments to creating the necessary conditions for country ownership to take place. Action is particularly needed in three areas:

·        Implementing transparency and accountability mechanisms. This is particularly important in the area of financial resources. National budgets and allocations need to be transparent and accessible by the public at both central and decentralized levels.

·        Setting up institutional mechanisms for the participation of CSOs in national development policies, going beyond the consultative level, and allocating the necessary resources to facilitate such participation.

·        Strengthening the role of parliaments and involving them in national development strategies.  In too many countries, parliaments are weak and unable to influence policy development or to check and balance government actions.  Country governments are responsible for undertaking the necessary reforms for national parliaments to ensure a feedback and approval process for national development plans.  Once this has been achieved, the creation and support of parliamentary committees on poverty reduction instruments, like PRSPs, and budgeting committees can be an effective way to promote parliamentary input and monitoring.  Finally, parliamentarians need full information on all aspects of development assistance – including information on donor funding outside of the budget and from vertical initiatives.

Civil Society Responsibility  

SRHR NGOs and other members of civil society play a vital role in ensuring that country ownership principles are realized by:  

·        Advocating for full stakeholder participation in development processes and setting up the necessary mechanisms (such as transparent and wide-ranging election of representatives) to ensure that marginalized constituencies, as well as those operating outside of the capitals, have a seat at the table.

·        Building their capacity to understand and analyze national budgets, and track the expenditure of resources at the central, regional and local levels. Indeed, CSOs have a major role to play in producing reliable and independent information on such expenditures and whether or not they deviate from international commitments assumed by governments in areas such as SRHR, HIV/AIDS and aid effectiveness.   By monitoring government’s allocations of financial resources, SRHR NGOs and other CSOs can make an enormous contribution to the promotion and achievement of a key aspect of country ownership - budgets that are responsive to the needs of the citizenry.    

·        Building the skills of key stakeholders, not only at the central, but also at the regional and local levels, to participate in and monitor development strategies.  

·        Organizing themselves in networks and coalitions to monitor and track accountability at national and global levels as well as informing and mobilizing the general public in support of inclusive country ownership policies and actions.

·         The watchdog role mentioned above should also encompass the development of a tool for the assessment of country ownership. The tool would provide a manageable number of clear, results-oriented indicators addressing key aspects of country ownership agreed upon by CSOs at large and members of the SRHR community in particular.  The indicators would range from the recognition of the role and rights of CSOs to their institutionalized participation in national decision-making processes and the level of civil society and SRHR input reflected in approved development policies and instruments such as PRSPs, Country Coordinating Mechanisms (CCMs) and others. The assessment tool would also clearly identify which constituency (central government, parliament, CSO, etc) is responsible for achieving the results.

As equal partners in country ownership efforts, CSOs also need to develop effective transparency and accountability mechanisms vis-à-vis the members of their own communities and constituencies as well as donors and recipient governments. The existence and availability of clear activity and financial reports are good examples of such mechanisms as is the capacity to undertake internal evaluations and the openness to be the subject of external reviews and audit processes.

To conclude, as a keystone of many new development financing mechanisms, country ownership is a principle that deserves continued effort. As the concept of country ownership continues to be debated and processes for its implementation continue to be developed, the SRHR and the broader civil society community have an important opportunity – through thoughtful development and implementation of country ownership principles –  to strengthen their voice in the design and implementation of development strategies. This is especially critical to SRHR issues, which require strong champions at the country level. The challenge is to ensure that donors and country governments are held accountable to commitments made. To meet that challenge, SRHR organizations must develop new knowledge and capacities in order to both advocate for a seat at the table and function effectively once there.

Carolyn Gibb Vogel is a senior research associate at Population Action International and acting director of research.

Mercedes Mas de Xaxás, based in Barcelona, Spain, is an international policy and advocacy consultant to PAI.

Ethiopia is a poor country with weak health care systems and other infrastructure.  Reproductive health, like most aspects of health in Ethiopia, is generally poor, with significant regional disparities in access to services and in health outcomes.  Almost 80 percent morbidity in Ethiopia is due to preventable communicable and nutritional diseases, both associated with low socio-economic development.1 Improving the general physical infrastructure and strengthening health systems are key to improving health and require major investments and much time.

In the absence of a well-functioning health care infrastructure, initiatives that complement traditional health care provision help reach specific population groups, communities or geographical areas. Here we will highlight two such initiatives. The first is an ambitious government-led community health service delivery program that is national in scale. The second is driven by a non-governmental organization and is locally-developed and -owned and is taking root in one region in Ethiopia.

Uneven access to services and health outcomes

The diversity of socio-economic environments, climates, and terrains among regions in Ethiopia greatly impacts health conditions and outcomes. Poor health coverage is of particular concern in rural Ethiopia, where access to any type of modern health institution is limited at best.  Health systems and roads are underdeveloped, and transportation problems are severe, especially during the rainy season. 

Almost all births take place at home in Ethiopia (94 percent) with only six percent of women delivering in a clinic or hospital.  Many of these women live in remote areas that are too far from a road, let alone a health facility where they can receive emergency obstetric care.  The majority of these births (61 percent) are assisted by a relative or some other untrained person and five percent are delivered without any assistance.2  Less than 28 percent of all Ethiopian mothers receive prenatal care from a trained doctor, nurse or midwife.  The quality and frequency of this care is variable; many women receive the care either too late in their pregnancy or too few times.3  

Women in Ethiopia are at a very high risk of death during pregnancy and delivery.  One in 14 Ethiopian women faces the risk of death during pregnancy and childbirth.4 The risk is higher among rural, poor and uneducated women.  Infant and child mortality are equally high; one in every 13 Ethiopian children dies before its first birthday and one in 8 dies before age five.  Across the board, mortality is lower in urban than in rural areas in Ethiopia.5 High maternal and infant mortality are reflective of the low socio-economic status, including public health services and health-care infrastructure.

Urban women marry two years later than rural women on average. Marriage at the age of 7 or 8 is not unheard of in rural parts of Ethiopia.6 Such early marriage and consequent pregnancy is one cause of higher rates of maternal and infant mortality and morbidity, including from obstetric fistula, and increased vulnerability to sexually transmitted infections (STIs), including HIV.

Contraceptive use, although it has increased consistently over the past decade, remains low with only 15 percent of currently married women using a method of contraception.  Women in urban areas are four times more likely than their rural counterparts to use contraception (42 versus 11 percent).7  

There are significant regional differentials in fertility.  On average, Ethiopian women have 5.4 children during their lifetime, but women in rural areas tend to have significantly larger families (6 children) than women in urban areas (2.4 children).8 These differentials in fertility are, however, consistent with regional differentials in fertility preferences; people in rural areas favor bigger families. 

Infection with HIV is one area where rural areas fare better than urban areas. National HIV prevalence Ethiopia was estimated by the Demographic and Health Survey at 1.4 percent among adults aged 15-49 in 2005.  Prevalence is much higher in urban areas (6 percent) than in rural areas (1 percent).  It is twice as high among women (2 percent) than men (1 percent).9  

Discrepancies in access to health services are not limited to reproductive health. Vaccination rates vary significantly between rural and urban areas; vaccination coverage in urban areas is three times that of rural areas. Malaria is a major health problem and cause of mortality and is the leading cause of outpatient visits in Ethiopia. 

Improving access and equity: The Health Extension Workers program

The government is the main health provider in Ethiopia but the coverage and distribution of its health facilities among regions remains uneven. It is, however, seeking to address inequities in health service delivery through its Health Extension Program (HEP).  This program aims to improve access to basic essential health services in severely under-served rural and remote communities, with the goal of achieving universal primary health care by 2009. Infrastructure challenges faced by the program are great: deteriorating transportation infrastructure and road conditions, inadequacy of primary health care facilities, shortages of trained health workers, unreliable supply of health supplies, and weak health information, vital statistics and administrative systems.

Expanding physical health infrastructure and developing a cadre of Health Extension Workers (HEWs) who will provide basic curative and preventive health services in every rural community are strategies that the HEP is applying to meet these challenges. By 2009, a total of 30,000 extension health workers will receive one year training and will be deployed in villages to provide basic curative and preventive health services. Prevention and control of communicable diseases such as providing malaria bed nets, health education, and contraceptives, with active community participation, are priorities of the HEP. This program, including procurement of medical supplies, drugs and commodities, is supported by several external donors.

The primary health care system in Ethiopia is comprised of a health center with five health posts attached to it. The HEP will assign two HEWs to each health post. In addition, thousands of other health care service staff, mostly at the health center level, will receive training as part of the HEP. 

This community level service provision is much needed especially in a context of increasing demand for services. Demand for family planning, for example, though still weak, is increasing. In rural areas in Ethiopia, there is much room for expansion of family planning services – in access and quality. Poor quality of services such as interrupted availability of contraceptive supplies, limited method mix,[1] and family planning knowledge through counseling about method choice and side effects, can be as much of a barrier as lack of physical access to services.10 

Just like the government, the non-governmental community in Ethiopia is also employing community-based strategies to help improve health outcomes where access to health services and information is weak. Community participation and working at the local level facilitates change in attitudes towards gender norms that adversely affect health. 

Implementing programs in context: Kembetta Women’s Self-Help Center

For the past decade, since its founding in 1998, Kembatti Mentti Gezzimma (KMG), or Kembatta Women’s Self-Help Center, has been working to empower women at the individual and community levels and ensure that their constitutionally granted rights are well-known and well-protected. To empower communities and especially women, KMG links social, economic and political aspects of change. For example, it educates women on the electoral process and provides leadership training to young women as well as works with police and attorneys to uphold and enforce laws protecting women from violence.

Through a process of community involvement in both the development and execution of interventions, KMG works directly with women and other local community member it is trying to reach, ensuring a focus on local needs and promoting self-reliance. The organization works to achieve community consensus, structuring programs on the strengths and traditions of each community.

One of KMG’s successes has been its work on reducing female genital cutting (FGC), which was, until recently, a nearly universal practice in the Kembatta area in Southern Ethiopia, where KMG originated.  Through its community-based programs, KMG helped parents, husbands and wives, and young women understand the many harmful effects, both physical and emotional, of FGC. For example, KMG has been successful at educating the community about the epidemiological connections between FGC and increased risk of contracting HIV and with complications during childbirth, as well as highlighting the lack of religious justification for the practice.

KMG tackled a practice believed to be at the heart of the religion and culture of many Ethiopian communities. Not only is the practice of FGC declining in many communities, but the communities and their elders are publicly celebrating the end of the practice; communities now organize celebratory rallies that have attracted nearly 20,000 people at a time, including entire villages and their elders.  

KMG has introduced reproductive health curricula into local schools, constructed clinics for maternal and child health and for HIV/AIDS testing, prepared adults and young people to be community-based health workers and classroom peer educators. KMG is working to improve the health and overall status of women by providing needed services while affecting local socioeconomic change which would change attitudes and gender norms that adversely affect health. 

Conclusion

The reproductive health needs in Ethiopia are great, and so are the challenges to providing more equitable access to health information and services.11  With a poor transportation infrastructure and the limited reach of the formal public sector health infrastructure, men and women residing in rural and remote areas can neither be assured that a health outlet is reachable nor that when one is reached, it will contain the needed health supplies and services. This is especially important for pregnant women whose timely referral and arrival to adequate facilities in case of emergency are essential to her survival and that of the baby. These challenges include having a much-needed system-wide approach to improving roads and other transportation and communication systems as well as strengthening the health system altogether. 

In this context, reaching the poor and those in remote areas can be delayed due to weak infrastructure. Strengthening the primary health care system and decentralizing health service provision facilitates reaching those living in remote and hard to reach rural areas. At the same time, mobilizing, educating and training communities and individuals is empowering to communities and individuals in those communities. Programs described are—by providing reproductive and other health services through primary health care facilities, paying attention to quality of services, and strengthening community participation—working to improve equity of health service delivery within the context of available infrastructure and weak systems. 

The Context: Sex Work and Condom Stigma

The HIV epidemic in the Dominican Republic has followed a typical trajectory from an initial epidemic driven by men who have sex with men, to today’s generalized epidemic. As in many countries, the spread of HIV/AIDS is now led primarily by heterosexual sex and is highly contingent upon prevalence among commercial sex workers. While sex tourism is increasingly pervasive in the Dominican Republic (and in the Caribbean region in general), local men still form the mainstay of the country’s sex trade. ² Thus, HIV prevention among the estimated 100,000 female sex workers and their clients is critically important to curbing the country’s AIDS epidemic.

Starting in the mid-1990s, HIV prevalence at antenatal clinics in Santo Domingo, the capital city, began to decline. UNAIDS attributes this trend to efforts to promote safer commercial sex in the city.³ In recent years HIV prevalence in pregnant women has remained relatively stable at 1.4 percent, but was as high as 2.7 percent in some areas according to the 2004 round of sentinel surveillance.⁴ National adult prevalence was estimated to be 1.1 percent in 2005.⁵ On the other hand, HIV prevalence among female sex workers currently ranges from 1.1 percent to 12.4 percent, depending on the locale.⁶ Lower prevalence in some regions is reflective of intensive interventions by nongovernmental organizations. HIV prevalence is also disproportionately high—estimated at 5 percent in 2002, and jumped as high as 12 percent in men between 40 and 44 years old—in former sugar plantations, known as bateyes.⁷

FIGURE 1: HIV Prevalence Among Sex Workers in All Provinces for Which Data is Available, 2004.

Source: Sistema de Vigilancia Centinela de la Infección VIH. 2004. Programa de Control de Infecciones de Transmisión Sexual y SIDA (PROCETS) de la Secretaría de Estado de Salud Pública y Asistencia Social (SESPAS).

Bateyes were initially settled by Haitians, who were encouraged to enter the Dominican Republic as a source of cheap labor. Since the collapse of the sugar plantations, the majority of bateyes in the country have become communities of extreme poverty populated by Dominicans, Haitians, and Haitian-Dominicans. Sex work in the bateyes was originally fueled by disproportionate gender ratios, caused by the demand for male labor on the plantations. Continuing high rates of sex work, in the context of limited access to essential health care services and education, contribute to inflated HIV prevalence in the bateyes.

With no specific prohibition in law, sex work in the Dominican Republic is effectively legal. The vast majority of sex work is conducted from direct or indirect establishments, as opposed to work on the street.⁸ Direct establishments mainly consist of brothels or casas de citas, but indirect establishments, such as bars and discos, are far more common. In the case of indirect establishments, sex usually occurs at nearby motels, which are mandated by law to provide two free condoms in each room.

Condoms are highly stigmatized in the Dominican Republic, in part due to embedded Catholic ideologies and pervasive gender roles. Throughout the 30-year span of the country’s HIV epidemic, condom use among stable, long-term couples has remained low at less than two percent, although this trend is beginning to change among the young, single, educated population.⁹ Because condoms are associated with infidelity and sexually transmitted infections (STIs), most female sex workers report that condom use is easiest with their clients as opposed to stable partners.¹⁰ SURVEY results have shown that consistent condom use with non-paying partners is typically much lower than with paying partners; this is particularly significant considering that the majority of sex workers report some sort of regular partnership.¹¹

The Strategy: Addressing Individual HIV Risk Behaviors

Working against these odds, the Dominican Republic has succeeded in promoting consistent condom use and other safe behaviors among sex workers. Since the early 1990s HIV prevalence has declined in Santo Domingo and the surrounding areas, as shown in Figure 2. In fact, HIV prevalence among sex workers declined in all regions for which time series data are available, with the sole exception of Peravia, where prevalence is estimated to be 12.4 percent, the highest reported. Of sex workers recently surveyed in the capital, 87 percent reported using a condom during the last commercial sex act, and 76 percent said they always used a condom during paid sex.¹²

FIGURE 2: HIV Prevalence Among Sex Workers Declined Steadily Between 1991 and 2004 in Santo Domingo and the Surrounding Areas.

Source: Sistema de Vigilancia Centinela de la Infección VIH. 2004. Programa de Control de Infecciones de Transmisión Sexual y SIDA (PROCETS) de la Secretaría de Estado de Salud Pública y Asistencia Social (SESPAS).

It is arguably NGOs, as opposed to the government, that have been the driving force behind these successes.¹³ Strategies have evolved from an early approach of peer education outreach in the 1980s, to targeted and intensive social marketing of condoms.¹⁴ Two organizations that have been instrumental in these efforts are Centro de Orientación e Investigación Integral (COIN) and Movimiento de Mujeres Unidas (Modemu). COIN first began organizing sex workers as health messengers in a peer education program aimed at HIV/STI prevention in 1987. In 1995 COIN organized the first national conference of sex workers, at which time Modemu was formed. Modemu is a union of approximately 400 sex workers that conducts outreach for HIV/STI prevention and lobbies for policy change concerning medical and legal attention, as well as recognition of labor rights.

COIN and Modemu are also two among the six local NGOs that partner with Population Services International (PSI) to distribute condoms for social marketing. Each organization distributes the condoms in a certain zone of the country, with a specific mandate to reach sex workers. The condoms are sold at locations where concentrations of sex workers are high, such as small corner stores and also in pay-by-the-hour motels. PSI estimates that roughly one million condoms are sold each month through these local partners.

The Strategy Evolves: Considering Community and Policy Approaches

Following in the footsteps of several successful Asian models, the Dominican Republic has recently begun to address the underlying socio-cultural and environmental factors that influence HIV risk behaviors. The aim is to extend beyond individual approaches to broader community approaches and policy initiatives. PAI’s July Research Commentary profiled the well-known case of the 100% Condom Use Program (CUP) in Cambodia, which required condom use in every sexual encounter between commercial sex workers and their clients. Similarly, pilot adaptations of the Thai 100% condom use model were implemented in two Dominican cities (Santo Domingo and Puerto Plata) in a joint effort by two local NGOs and the National Program for the Control of STDs and AIDS.

Qualitative and quantitative research were conducted between 1996 and 1998 to inform the process of adapting elements of the Thai model to the Dominican context.15 Results suggested that sex workers and establishment owners alike would be supportive of policies to regulate the use of condoms within sex establishments.¹⁶ Based on indications that such a program would be both acceptable and feasible, a “community solidarity” approach was implemented in Santo Domingo and Puerto Plata.¹⁷ The programs included quarterly workshops and monthly follow-up meetings with sex workers and establishment employees to encourage collective commitment toward HIV prevention. Environmental cues, such as posters and other materials were made more visible, and establishment owners were asked to maintain a stock of at least 100 condoms at all times. Moreover, the program sought to overcome inconsistencies in the monthly STI screenings mandated by the Ministry of Health by providing training to clinicians.

The elements of the program were evaluated on a monthly basis by government health inspectors and NGO staff, and status of adherence was communicated to establishment owners. In Puerto Plata, where the necessary political leadership was present, these initiatives were implemented in conjunction with a government policy that mandated condom use between sex workers and their clients in all participating sex establishments. The policy was enacted and enforced by the regional public health department, and non-compliant establishments were subject to notifications, fines and closings. ¹⁸

Emerging from these two programs, research has shown that public policy initiatives in the Dominican Republic can play a significant role in increasing the likelihood of condom use and reducing the prevalence of STIs. At both sites, researchers found that sex workers were significantly more likely to use condoms consistently with paying clients. However, in Puerto Plata where condom use was mandated by government policy, consistent condom use with regular, non-paying partners more than doubled—from 13 to 29 percent.¹⁹ Thus, by encouraging community solidarity, backed by political support, sex workers were more empowered to use condoms in both commercial and non-commercial settings.

Scaling Up the Role of Communities and Government

The implications of this study—that policy interventions in the Dominican Republic can empower sex workers to protect themselves, their clients and their regular partners—have led to the current scale up of the 100 percent condom use model in Santo Domingo and Puerto Plata. The challenge now posed to the country is to continue to scale up existing programs, and also to apply similar strategies and resources to the bateyes. Despite some NGO presence, the bateyes remain largely underserved and neglected. Only an estimated one-quarter of the bateyes are served by government health-care clinics, and the marginalization of these communities, along with language barriers and a wariness of offi-cialdom, often impedes the use of those services that are technically available.²⁰ Combating the spread of HIV in the bateyes will require improved surveillance and large-scale investments in social and legal infrrastructure.

The Dominican Republic provides an important precedent for other countries with similar epidemics to take steps to assess whether or not a version of the 100 percent condom program could succeed. Undoubtedly, there is a myriad of factors that influence HIV risk behavior, but this case illustrates that carefully tailored approaches to increase the involvement of communities and government can positively affect the environmental context in which individual behaviors take place. As with all successful HIV interventions, this deserves attention. Knowing that policy can empower sex workers to prevent the spread of HIV places an even greater burden upon political will.

Sarah Haddock is a research assistant at Population Action International and has worked in the Caribbean and Spain on development issues.

The lens of population age structure—that is, the proportional size of different age groups within a population—is useful for better understanding Nigeria’s development and that of many other countries. Age structures reflect a country’s present and past mortality and fertility trends, which can be extrapolated to broader health and development dynamics. Age structures also yield insights into national political and economic challenges, now and in the future.

Population Action International (PAI) has developed four major types into which all current and past national populations fit: very youthful, youthful, mid-age and aged age structures. As PAI’s forthcoming report The Shape of Things to Come: Population Age Structures and their Implications for Security, Governance and Economic Development explains, countries in each age structure category share similarities in important development indicators: their governance type, economic development, and vulnerability to civil conflict. Although population dynamics provide only a partial view of a country’s current and future risks and opportunities, the associations found in comparing age structures suggest that demographics should be a component of all country analyses. A case study such as Nigeria’s can help policymakers see how the relationship between population and development has evolved in a specific case, and how its findings might be carried over to other countries.

Nigeria is firmly within the category of a very youthful age structure, with nearly three-quarters of its population under the age of 30. Among the 62 countries in the very youthful category in 2005, at least two-thirds of the population was generally under age 30 and just three to six percent was older than age 60. These countries are in the early stages of the demographic transition: the shift from large families and short lives to small families and longer lifespans. However, in some cases, countries’ initial success in reducing birth and death rates has not been sustained over time. Nigeria’s population has actually grown more unbalanced in recent decades. Between 1975 and 2005 the share of young people in the country’s population increased while the share of older adults slightly decreased, and thus Nigeria has reversed course along the path of the demographic transition—an anomaly in the process of most countries’ development.

FIGURE 1: NIGERIA’S AGE STRUCTURES, 1975 AND 2005²

These two population profiles compare the size of different age groups in Nigeria’s population in 1975 and in 2005. The bars along the left side represent males, the right side, females; each bar shows the relative size of a five-year age cohort in ascending age. In both of the years shown, Nigeria’s population maintains the classic pyramid shape of a very youthful population, with progressively larger proportions among each successively younger age group.

Nigeria’s regression along the demographic transition can be explained by its stagnant death rate and only slightly declining birth rate. Mortality rates have barely changed since 1975, from 20 to 19 annual deaths per 1,000 people. Total life expectancy is around 44 years for men and women, a decline from previous decades. Meanwhile, the total fertility rate dropped from 6.9 to 5.9 children per woman between 1975 and 2005, but remains extremely high. As fertility and mortality rates have remained high, the momentum of population growth has led the share of children and adolescents within the population to increase, making Nigeria’s age structure even more unbalanced.

Only eight percent of married women of reproductive age use a modern method of contraception. This may in part be because desired fertility is very high—the number of children Nigerian women say they want is nearly seven. A number of factors may explain high desired fertility, including poor child survival rates and low educational attainment among women. One-fifth of all children born in Nigeria die before they turn five, and 42 percent of women have never attended school.³

Although many previous international development projects yielded poor results, Nigeria and its donors have taken steps to reduce its debt to foreign creditors. Through currently active projects, the World Bank is funding nearly $2 billion in development assistance to the country. Still, one-third of the population lives in poverty, and Nigeria is among the 20 poorest countries in the world.

Nigeria’s population more than doubled between 1975 and 2005, and it is projected to increase by 40 percent by 2025. As measured by population size, the country is currently the ninth largest in the world. Even if its fertility and mortality rates begin a rapid decline, Nigeria will have a youthful age structure in 2025. Now that the country has established a democratic government and increased support from international donors, priority must be given to improving its people’s standard of living. Age structures can and have been influenced by populationrelevant policies and programs. In particular, expanding access to family planning and reproductive health care, education for girls, and economic opportunities for women can enhance development and improve the prospects for global security. Improvements in health and economics would likely lead to a much more stable situation for one of Africa’s leading states. Critical areas include maternal and child health, greater access to basic education, increased use of contraception, entrenchment against HIV/AIDS and other infectious diseases, and a more equitable distribution of wealth, together with other programs to diversify and balance the economy.

As shown in Figure 2, there are a range of demographic possibilities for Nigeria within the next 20 years. The United Nations produces future population projections at two extremes, a low- and high-fertility variant, each of which assumes vastly different future birth rates. As can be seen in the profile, if fertility declines rapidly in Nigeria to about three children per woman, the proportion of its population composed of age groups under 30 will begin to even out and produce a more stable age structure. This could occur if priority attention is given to both mortality and fertility aspects of health by the country’s government and its partners. However, if total fertility declines from today’s rate of more than five children per woman to four, Nigeria will maintain its current unbalanced very youthful age structure,