Family Planning Summit: dilemmas of UK exceptionalism, private v public and population control

Are we now in a period of global British exceptionalism in aid and development, and if so, what are the implications for the work of British-based NGOs and their allies? That question has been niggling away at me during the run-up to the big UK government + Gates Foundation ‘Family Planning Summit’ tomorrow.

Why exceptionalism? Because the UK is pretty much alone among traditional donors in sticking to its promises to increase aid despite deep public spending cuts, and is simultaneously pushing ahead in the multilateral arena, with a Hunger Summit scheduled during the Olympics, tomorrow’s Family Planning Summit and David Cameron as one of the three co-chairs (with the leaders of Indonesia and Liberia) of the UN panel to look at what comes after the MDGs.

That leadership places organizations like Oxfam in an extreme ‘cup half full/empty’ quandary. There are strong arguments in both directions: should we join in as a cheerleader, building UK public support for the government’s brave (and among some of the right wing press, deeply unpopular) stance, bigging up its leadership to try and shame other governments into following suit? To do that means biting our tongue on some unpalatable aspects of the government’s policies we just don’t think will be effective (see below).

Or should we opt for the role of critic, stressing our areas of disagreement, or what still needs to be done. That may be truer to our convictions and analysis, but it risks undermining public support for aid, losing the chance to influence other countries, and, let’s be honest, landing ourselves in a big row with the government. The standard NGO default of chucking in a congratulatory first paragraph, and then starting the second para with ‘But…..’ doesn’t fool anyone because, as a civil servant once informed me, everyone knows that ‘everything above the ‘but’ is bollxxks’.

So back to the summit. First the stats, which you will see endlessly rehearsed if the organizers get their media work right. 215 million women and girls in developing countries who want to delay, space or avoid becoming pregnant are not using effective methods of contraception, resulting in over 75 million unintended pregnancies every year. This puts women and girls at serious risk of death or disability during pregnancy and childbirth, including from unsafe abortions, particularly where quality of care is inadequate.

If those 215 million women and girls used modern methods of family planning, unintended pregnancies would fall by more than 70 percent, and each year there would be nearly 100,000 fewer maternal deaths and nearly 600,000 fewer newborn deaths. 

In response, the Summit is launching an effort to ‘make available affordable, lifesaving contraceptive information, services, and supplies to an additional 120 million women and girls in the world’s poorest countries by 2020.’ i.e. halve the number of women excluded from family planning systems. That’s amazing, especially in times like these. Hats off. Get out there and support this.

So (and carefully avoiding use of the word ‘but’) why the lingering discomfort? Let’s pick three issues: supply v demand; private v public and population. Of these, I think the first is debateable, the second substantive, and the third is a framing issue that I hope we can sort out quickly.

It's about systems, not just contraceptives

important question of balance. Solving the shortfall in sexual and reproductive health services (this is about much more than contraceptives) is as much about systems as stuff. I’m not completely clear from the documents I’ve read, but the concern is clearly that the summit is skewed towards stuff, although Andrew Mitchell, the UK Development Minister, clearly backs demand-side rights when he says the summit is about “poor women who want contraception but can’t get it. We’re trying to ensure that women have the opportunity to decide for themselves.” 

Private v public: on health issues, this is probably the most genuinely divisive topic. To what extent are health services like family planning best delivered free at the point of use via a public health system, or should the preference be to involve private sector delivery mechanisms. Oxfam’s reading of the research suggests the benefits of the latter approach are unproven, but the organizers clearly want to involve the private sector to a significant extent – is the underlying driver ideology or evidence?

Population: The Summit is being held on World Population Day. Depending on your viewpoint, that is a brave attempt to take on the ‘too many Africans’ school of population controllers, and reassert what really matters in this debate – women’s ability to exercise control over their fertility (and to be fair, the population lobby have moved a long way towards women’s rights in recent years). Or it’s a dangerous conflation of two issues that are related, but not nearly as closely as some controllers make out. My colleague Ricardo Fuentes has been crunching the numbers on one aspect: how important is population growth in poor countries to climate change (see previous post on this)? The answer is not very much. In the 25 years to 2005, Sub-Saharan Africa accounted for almost a fifth of the growth in the world’s population but only 2.4 per cent of the increase in CO2 emissions. By contrast, North America was responsible for 4 per cent of population growth but 13.9 per cent of the rise in emissions (i.e. nearly 6 times as much as Africa). Attacking climate change through population control would mean reducing the number of Americans, not Africans (not a policy I would espouse by the way – some of my best friends etc).

So there’s my ‘cup half full/empty’ summary. It’s fine for the blog, but too complicated for soundbites. That’s where the trouble starts.

What else to read? Here’s the increasingly impressive Melinda Gates making the case in the Guardian and voicing over (voiceovering?) a youtube animation setting out the economic rationale

An evening with Bill and Melinda Gates and the decade of vaccines: is this the future of aid?

On Monday night I joined the besuited masses of the UK development scene to sit at the feet (OK, in a crammed 400 seat lecture theatre) of Bill and Melinda Gates as they promoted the ONE campaign’s ‘Living Proof’ project on effective aid. It was great to hear an optimistic message on aid and development for once, especially when it was laid out brilliantly in front of an audience that included a good number of journos.

But it was also weird, not least because they took an hour to try and convince an audience made up largely of aid workers of the merits of aid – not the toughest ask Bill has faced in his career. In fact it sometimes resembled a viva, as the Gateses strutted their stuff before their peers, ably supported by Dr. Debrework Zewdie (right), deputy director of the Global Fund. And they definitely passed, especially Melinda who managed to combine authority and passion, while stopping just short of cheesy.

The chief object of their praise was the British government – two days before the announcement of its Comprehensive Spending Review (aid implications here), this was a very public endorsement from some pretty big fish of the coalition government’s commitment to increasing aid to 0.7% of GNI by 2013, despite the mayhem taking place in other departments. Andrew Mitchell, Secretary of State for International Development, was in the audience, and the Gateses dropped in on David Cameron to drive home their message. As they stressed business thinking, ‘return on investment’ and the need to increase impact assessment, backed by a blizzard of stats, it became clear just how influential the Gates Foundation has become in terms of the aid discourse both here and in the US.

Their main call was for what they termed a ‘decade of vaccines’: get universal distribution of existing vaccines for polio, measles etc and develop new ones for diseases such as malaria. I was struck by both the can-do optimism and the seductive certainties of the vaccine business – so many vaccines distributed = so many millions of lives saved and made healthy and productive. Inspiring stuff, and free of the messiness, complexity, politics and power struggles that usually characterize development. Just technology riding to the rescue, driven by philanthropy’s cash and willpower. And a stark contrast with the gloom that surrounds other issues like the failure to tackle climate change, or the huge complexity of trying to understand (let alone influence) political change. I was tempted – maybe this is what Big Aid should limit itself to – delivering concrete benefits, keep people alive, and leave the rest to national politics?

And yet. And yet. Inside my policy wonk head a nervous tic of ‘yes buts’ stopped me being completely won over. Bill played fast and loose on correlation v causality – OK, aid undoubtedly helped in countries like South Korea, but did Asia as a whole really take off because of aid (maybe I misheard that bit….)? Where do the effective state systems needed to deliver all these vaccines come from, and are big players like the Global Fund strengthening them or weakening them by setting up parallel systems? Surely, aid should help generate good politics as well as immunize kids, for example by empowering citizens to demand accountability? OK, it’s hard to do and hard to measure and a lot less easy to explain than vaccines, but we need Big Aid to do politics if it is going to work. Bill seemed to imply that the messy stuff was what other donors like DFID should be doing, but the danger is that vaccine-style aid actually crowds out the harder-to-measure activities.

The event was in a fantastic location – the British Science Museum. As I left through the half-lit exhibition halls, I passed lifesize replicas (or the originals, for all I know) of the Lunar Lander, and Stephenson’s Rocket. Science and Progress resplendent –technology is all you need. If only it was that simple.

3 minute Living Proof video here, but if you have an hour and half to kill, you can watch the whole event below (but make a cup of tea while it downloads……)