Meeting an unmet need for family planning.

More than 120 million women worldwide aged 15-49 years have an unmet need for family planning, which is due a renaissance after years of neglect. On 11 July 2012, the Bill & Melinda Gates Foundation and the UK government will co-host an international summit in London to shine a spotlight on the world’s massive unmet need for family planning. The summit hopes to catalyse a global movement to provide 120 million women in low income countries access to family planning by 2020. Achieving this target, which would bring vast public health benefits, will require new funding—no small order in a time of global fiscal constraint—combinedwith transformational cost effective approaches to increasing coverage. Women in sub-SaharanAfrica, about 35million of whom cannot access or use family planning, and those living with HIV, have the greatest unmet need. 3 In one Ugandan survey, three quarters of people infected with HIV (men and women) reported an unmet need for contraception, compared with a third of uninfected individuals (odds ratio 3.97, 95% confidence interval 1.97 to 8.03). Assuming a similar prevalence across the continent, we calculate that about 10 million HIV infected women in sub-Saharan Africa have an unmet need for family planning.What is more, pregnancy increases the risk of sexual transmission of HIV between discordant couples, through mechanisms that are poorly understood. The Guttmacher Institute and International Planned Parenthood Federation estimate that satisfying the global unmet need for family planning would prevent 53 million unintended pregnancies each year, resulting in 22 million fewer unplanned births, 25 million fewer induced abortions, and seven million fewer miscarriages.Around 90000women’s lives would be saved and 590000 newborn deaths would be averted annually.Unsafe abortions and unintended pregnancies are two of the most important causes of maternal deaths worldwide. Additional benefits include alleviation of poverty, empowerment of women, and enhanced environmental sustainability. Considering its low cost, family planning is a “best buy” in global health. It is therefore surprising how far reproductive health has fallen off the radar of the global health community. As a proportion of total health aid to all developing countries, aid for family planning fell from 8.2% in 2000 to 2.6% in 2009, whereas funding for HIV rose from 3% to 26%. In the massive scale-up of HIV services the opportunity to deal with family planning at the same time was missed. As Babatunde Osotimehin, the executive director of the United Nations Population Fund, put it: “Wemade amistake; we disconnectedHIV from reproductive health. We should never have done that because it is part and parcel.” The forthcoming summit in London represents a tremendous opportunity to get family planning back on the global agenda and to “reconnect” it with HIV and other health services. Donors and high burden countries are arriving at an action plan with three broad components.The first is to raise newmoney—$4bn (£2.8; €3.2bn) over the next eight years—to fund country led scale-up plans that can tackle key bottlenecks, such as limited supplies of effective contraceptives and lack of skilled providers, rapidly. Even if $4bn can be raised, this would be far short of what is needed to provide comprehensive family planning services worldwide—for example, Speidel and colleagues estimate that $15bn would be needed annually, including $5bn from donors. The second is to launch market interventions, such as new public-private product development partnerships, aimed at increasing the availability and quality of low cost and effective family planning methods. The third is to monitor and evaluate whether these strategies actually help improve provision of family planning. Reaching the ambitious 2020 target will require innovative and highly cost effective approaches to scaling up services. Given the links between HIV and unmet need for family planning, it seems sensible to integrate reproductive health into HIV services as well as maternal and child health services. A 2009 systematic review of 58 studies found that linking HIV and reproductive health services could enhance programme efficiency and effectiveness and increase uptake of services, coverage of underserved populations, and use of effective