An unmet need for sound thinking

Melinda Gates, one of the world's richest women, and the British government, organised a family planning summit in London this week. They should have done their homework first.
Michael Cook | 13 July 2012
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If you are not too greedy and need only a modest amount of other people's money, get a sawed-off shotgun and a balaclava. However, if you are more ambitious, get an acronym. This is clearly the lesson to be drawn from the latest banking scandal, in which Britain's leading banks scammed US$300 billion, perhaps much more, by fibbing about the Libor -- the London Interbank Offered Rate -- an acronym which politicians had never heard of and regulators hardly questioned.

But the same mistake was made all over again at this week's London Family Planning Summit. The rich and famous of the world have donated $2.6 billion to meet the "unmet need" of 120 million women in the developing world for family planning. The UK has pledged $800 million, the Bill and Melinda Gates Foundation $560 million, the UNFPA $378 million, Norway $200 million, the Netherlands $160 million, and Germany $122 million. Those are just the donors in the hundreds of millions.

Do any of these governments and organisations really know what $2.6 billion of "unmet need" means? In a year when voters in some countries are rioting over "austericide" in the wake of the global financial crisis, are they tipping money into a gigantic black hole?

A professor at Harvard University's Kennedy School of Government, Lant Pritchett, told MercatorNet that "unmet need" is a meaningless concept employed by no one except a coterie of family planning experts. Pritchett, who was described last year as one of the world's 100 top global thinkers by the magazine Foreign Policy, was scathing in an email to MercatorNet. "Wow, I thought all of this was dead and gone... I wonder what is driving this revival?"

"It has never caught fire except in a tiny group that push and push and naif outsiders assume they know what they are talking about and take it at face value. No one who has looked at it closely… really thinks it has any analytic use other than advocacy value. I am just amazed this nonsense has come back from its well-deserved dustbin of history."

The argument which has diddled some of the world's richest governments and philanthropists was set out this week in a special family planning issue of Britain's most prestigious medical journal, The Lancet. Melinda Gates and Australia's foreign minister, Bob Carr, contend that "Across the developing world, some 222 million women who want to avoid pregnancy are not using a modern method of contraception". Providing them with contraceptives will -- they claim -- lead to 600,000 fewer newborn death and 79,000 fewer maternal deaths each year. With fewer children, women will have more money to spend educating their daughters. And with fewer people there will be a "demographic dividend" allowing more economic growth.

The $2.6 billion pledged at the Summit will reach 120 million of the 222 million women with an "unmet need" for contraception.

"Unmet demand" was dreamed up in the first family-planning surveys in the 1960s. Its high-water mark was the Cairo population conference in 1994 which resolved that: “Governmental goals for family planning should be defined in terms of unmet needs for information and services”. As the organiser of the London summit, Melinda Gates has breathed new life into the idea. But as Pritchett points out, there have always been knotty problems with “unmet need”.

First of all, "unmet". According to a World Bank briefing note, women with "unmet need for contraception" are those "who do not want to become pregnant but are not using contraception". Astonishingly, this includes women who are currently pregnant, women who are breast-feeding, and women who find it difficult to become pregnant. The World Bank blandly acknowledges that "women with unmet need may still not have any intention to use contraception were it readily accessible and of good quality".

In other words, Melinda Gates's 220 million women include women who know all about contraceptives, can access them, and can pay for them. But they are worried about side effects, or they have religious objections or they have husbands who are working overseas. This makes no difference. Even if they don't want contraception, Mrs Gates and her supporters know that they need contraception. "Note that the measurement of unmet need," says the World Bank, "does not include an assessment of whether women want or intend to use contraception." Even Africa's 65,000 Catholic nuns fit into that definition.

"The strange thing is," says Pritchett, "that one of the stalwarts of the family planning movement, Charles Westoff, wrote a paper decades ago showing many of the same criticisms of ‘unmet need’ – eg, that is does not correspond to what women want, that it includes women not currently fecund, etc. -- but then they just went on using it anyway."

Second, "need". What does "need" for contraceptives mean to a woman? Does it mean "desperation" -- Mrs Gates seems to think so -- or does it mean "like"? A woman staggering through the Sahara is desperate for a drink; a woman staggering through a bar would like (another) one. In Mrs Gates's books, both of them have an "unmet need". But among the 220 million women, should those who are just vaguely interested in contraception be counted?

In a thought-provoking paper which Professor Pritchett wrote in 1996, not long after the Cairo Conference, he pointed out that in comparison to the need for food, water, medical care and fuel, the need for contraception was very small in poor countries.

"Contraception is a very effective technology for having unregulated coital activity and not having children but no one needs contraception in order not to have children. There is no question you need a parachute to jump out of airplanes and not suffer serious injury, but does that mean you need a parachute? Well, the need for parachutes is obviously only as great as the need to fling oneself out of planes, which is pressing if you’re in the 82nd Airborne, but not really otherwise."

Third, the idea of "unmet need" is patronising, even demeaning, for women. How can they "need" something that they do not want? This kind of reasoning comes from a patriarchal mindset. Women in developing countries are already pushed around too much. They should be allowed to make their own choices in peace. Pritchett told MercatorNet:

"This is exactly like calculating the ‘unmet need’ of Jewish people for pork. That is, one could do the calculations of the 'need' for protein, look at which Jewish people are getting enough protein, conclude that the experts think the most cost-effective way of getting protein is pork and then attribute an ‘unmet need’ for pork to people who are Jewish. Of course it is completely disrespectful of women to not listen to their reasons for not using contraception and insist they have a 'need' for something they do not 'want'. It is precisely this kind of disrespect for women and their autonomy and choices that led to the disasters in India and China."

Fourth, "unmet need" may possibly make sense in marketing, but as an analytical tool, Pritchett says, "it makes no economic sense at all". Even in underdeveloped regions, women are well aware of the existence of contraception. If demand for it were high, the price should rise. In fact, family planning organisations often have to work hard to give contraceptives away.

As Pritchett points out in his 1996 paper, it is not a question of price. Even poor households in countries like Indonesia and Nepal spend between 2 and 3 percent of household income on tobacco. "If the household can afford tobacco the household can afford contraception," he wrote.

More recent research shows that the use of contraceptives in developing countries does not decline if their price rises. This suggests that the problem is lack of demand, not lack of supply. American academics examined sales of contraceptives during the severe financial crisis which hit Indonesia in the late 1990s. They found that "very large changes in prices of contraceptives have little impact on the decision to use contraceptives or on method choice, even among the poorest couples."

In an interview with The Guardian about the Summit Melinda Gates described improving access to contraception across the globe as her life’s work. Unfortunately, a gremlin in the typesetting had her claiming that 200 billion women wanted access, rather than 200 million. But perhaps when you are dealing with esoteric matters like Libor or “unmet need”, billions and millions, whatever, all sound the same. As long as the donors feel good about themselves and family planning bureaucrats continue to draw their paycheques.

Michael Cook is editor of MercatorNet.  

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