Health And Rights In Low- And Middle-income Countries .
OPENCONSULTANTSFunding for sexual and reproductivehealth and rights in low- andmiddle-income countries: threats,outlook and opportunities
STUDY COMMISSIONED BY:The Partnership for Maternal, Newborn & Child Health20, Avenue AppiaCH-1211 Geneva 27SwitzerlandDEVELOPED BY:Open ConsultantsCantianstr. 2210437 BerlinGermanyAUTHORS:Marco Schäferhoff,1 Shantih van Hoog,1 Sebastian Martinez,1 Sara Fewer,1 Gavin Yamey2¹ Open Consultants, Berlin, Germany2Duke Global Health Institute, Duke University, Durham, NC USACONTACT:Marco Schäferhoff, Managing DirectorEmail: mschaeferhoff@openconsultants.org Photo credits:Flickr Creative Commons/UNICEF Ethiopia/2014/Nesbitt/NYHQ2014-3665/Coverphoto
ContentsContents1Executive Summary21. Introduction6The need for sustainable SRHR financing6Political threats to SRHR funding6About this new report72. Methods93. Trends in donor funding for sexual and reproductive health and rights104. Forecasting ODA for health and SRHR145. Government expenditures for SRHR and health in low- and middle-income countries18Government expenditures for reproductive health in low- and middle-income countries18Government expenditures on health in low- and middle-income countries19Forecasting government expenditures for health196. Conclusion and ces28Funding for sexual and reproductive health and rights in low- and middle-income countries: threats, outlook and opportunities1
Executive SummarySexual and reproductive health and rights (SRHR) are essential for reaching the Sustainable DevelopmentGoals (SDGs) for health. The Guttmacher-Lancet Commission found that meeting the unmet need forcontraception for 214 million women in developing regions would avert an additional 67 millionunintended pregnancies in 2017. If combined with full care for pregnant women and newborns,this reduction in unplanned pregnancies would reduce maternal deaths by 73% (from 308,000 to84,000) and newborn deaths by 80% (from 2.7 million to about 538,000).1Despite the substantial benefits of investing in SRHR, SRHR is a politicized topic in many countries. Antiabortion advocacy organizations are active worldwide, across the United States (US) and Europe,as well as in many low- and middle-income countries, including in Africa, Latin America, and theCaribbean.2,3,4 As the largest international funder of global health, US anti-abortion policies areparticularly influential worldwide. In 2017, President Donald Trump signed an executive order toimplement the Protecting Life in Global Health Assistance (PLGHA) policy, an expanded versionof the Mexico City policy, also known as the global gag rule.5 The policy prohibits US bilateralhealth funding for foreign non-governmental organizations (NGOs) that “perform or actively promoteabortion as a method of family planning.”To mitigate against the harmful effects of the Mexico City policy and other restrictions on SRHR, thedonor community has made significant commitments to SRHR. However, three things remain unclear:(i) the recent trends in donor funding for SRHR, (ii) how meaningful the commitments are in termsof additionality of funding, and (iii) how SRHR funding will evolve over time. SRHR funding couldbe reduced due to other priorities arising within and beyond the health sector. At the same time,donors expect low- and middle-income countries to increasingly self-finance health needs, basedon the assumption that these countries will experience significant economic growth. Yet the globaleconomic outlook has changed in recent years, challenging this assumption. Finally, while theGuttmacher-Lancet Commission emphasized that all countries should include SRHR in their pathtowards universal health coverage (UHC), and many countries are including common elements ofSRHR (primarily family planning, maternal, and newborn health) in their UHC packages and plans,inclusion of a full package of SRHR interventions is rare, and by no means guaranteed.This report seeks to take stock of current and potential future investments in SRHR, to help informdiscussions on how to ensure adequate support for SRHR. It provides analysis of SRHR funding bydonors and low- and middle-income country governments, which is crucial as much of the neededgrowth in SRHR funding will have to come from domestic sources. More specifically, the reportaddresses the following questions: How has donor funding for SRHR developed in recent years? To what extent have donorsincreased their SRHR funding in response to the reinstatement and expansion of the MexicoCity policy? What commitments have been made by donors in support of SRHR, and what will thefuture trend for SRHR donor funding look like? To what extent have governments of low- and middle-income countries increased their ownfunding for health and SRHR? How will domestic spending develop considering the mostrecent economic outlook?2Funding for sexual and reproductive health and rights in low- and middle-income countries: threats, outlook and opportunities
The report is based on a mix of methods, including document and budget analysis, an assessmentof major financial databases, key informant interviews, and quantitative modelling.Key findings1. Official development assistance (ODA) for SRHR and funding provided by the Bill & MelindaGates Foundation amounted to US 11.3 billion in 2017. While this is an all-time high,donors invested a lower share of their overall health funding in SRHR compared to previousyears. In this sense, donors deprioritized SRHR funding: they allocated 42% of their overallhealth funding to SRHR in 2016 and 2017, compared with allocating 52% of their healthaid on SRHR in 2011. Donor funding for non-HIV SRHR as a share of overall health aidalso declined, from 14.7% in 2016 to 12.5% in 2017.2. By far the largest share of donor funding provided for SRHR continues to be allocatedto HIV (70% in 2017). In contrast, investments in other key reproductive health careservices (e.g., antenatal and postnatal care including delivery, prevention and treatment ofinfertility, prevention and management of complications of abortion, and safe motherhoodactivities) only accounted for 16% of all SRHR donor flows in 2017. In comparison, 19%of all donor flows were invested in these other key reproductive health care services in2015. In addition, family planning funding provided by donors only accounted for 9% of allSRHR donor funding in 2017.3. Strong champions for SRHR in the donor community continue to support SRHR, amongthem the governments of Canada, Germany, the Netherlands, Norway, Sweden, and the UK.These donors increased their funding for SRHR in recent years. Many of these donors alsoaccounted for the increase in ODA for family planning – a key sub-area of SRHR – whichincreased from US 1.1 billion in 2011 to US 1.4 billion in 2018. The US governmentremains the world’s largest donor for family planning, accounting for 42% of all bilateralODA for family planning in 2018.4. Following the reinstatement and expansion of the Mexico City policy, donors made newcommitments to SRHR, including at the SheDecides conference in March 2017. However,while some commitments were truly additional, others were essentially recommitments ofexisting pledges made at previous events and occasions. This “rebottling” of investmentsmakes it hard to understand donors’ future investments in SRHR.5. Overall, the future of donor investments in SRHR beyond 2020 does not look bright –at best, key donors will slightly increase their SRHR investments, but it is as likely thatfunds will stagnate at current levels. There are five reasons for this prognosis: First, theInternational Monetary Fund just downgraded the growth forecast once again, which couldresult in cuts to overall ODA budgets as these are vulnerable to austerity measures. Second,key SRHR supporters have been maintaining or increasing SRHR budgets at relativelyhigh levels, which makes further increases unlikely. Third, health ODA (and within thatFunding for sexual and reproductive health and rights in low- and middle-income countries: threats, outlook and opportunities3
SRHR) will compete with other emerging donor priorities, such as climate change. Thereis also evidence that the development agencies of major donors face increasing pressureto shift their funding from social sectors to economic productive sectors. Fourth, the USgovernment’s anti-abortion policies may further restrain available resources for SRHR,unless other donors continue to increase their investments. Fifth, while the UK government– the second largest health and SRHR donor worldwide – recently announced a newcommitment, there is uncertainty around Brexit and how it will affect UK’s ODA.6. The Guttmacher-Lancet Commission estimated the cost for meeting all women’s needs forcontraceptive, maternal, and newborn care (the cost of HIV prevention and treatment wasexcluded). The costs for low-income countries (LICs) amounted to US 13.0 per capitaannually, which compares to current spending of US 1.1 per capita. The Commissionsuggested that the annual costs in lower-middle income countries (LMICs) would be lower,amounting to US 7.8 per head, compared to current average spending of US 5.2 in 2016.However, data are only available for 13 out of 45 LMICs and as such might overestimatespending levels in 2016. Eleven of the 13 countries spent well below US 7.8 in 2016 andonly two countries spent more.7. Due to the limited data on domestic SRHR spending, we assessed trends in overalldomestic government spending for health. The Lancet Commission on Investing in Healthfound that the annual costs of an “essential package” of 218 interventions to achieve UHCwould be about US 100 per head, while a more basic package of 108 “highest priorityinterventions” would cost US 50 per head. Many of these interventions are SRHR servicesaccording to the Guttmacher-Lancet Commission’s definition. Based on 2016 data, onlyeight LMICs would be able to afford the essential UHC package and 13 the more basicpackage, while only one LIC could afford even the basic package.8. Projections conducted for this paper indicate that in LMICs, average annual per capitaspending by governments would double, from US 59 in 2016 to US 108 in 2030 ifcountries were to increasingly prioritize health within their own budget. There is, however,variation between countries – 20 of them would be able to self-finance the essential packagewith 218 interventions, while 30 would be able fund the highest priority interventionspackage (108 interventions). Fifteen LMICs would still not be able to self-fund any package.In LICs, average annual per capita spending would increase from US 11 to US 18, withonly two out of 31 countries being able to self-fund the highest priority package. No LICwould be able to fund the essential package. This shows that most LICs will likely continueto rely on donor funding to finance health for the foreseeable future.4Funding for sexual and reproductive health and rights in low- and middle-income countries: threats, outlook and opportunities
Recommendations1. new global moment to mobilize political and financial support for SRHR is needed to sustainAinvestments. Global moments focusing on a particular issue have proven to be effective inmobilizing political and financial support by the donor community. The Family PlanningSummits in 2012 and 2017 and the SheDecides conference in March 2017 were successful in mobilizing financial resources and creating momentum. For example, the Beijing 25 conferences in Mexico City and Paris in 2020, and the International Family PlanningConference in February 2021, provide opportunities to generate such momentum again forSRHR.2. onors should include SRHR as an integral part of UHC efforts and protect health investmentsDvis-à-vis other emerging priorities. As part of their investments to help countries to reachUHC, donors need to explicitly include SRHR. Donors should work with countries to ensurethat everyone has access to an essential package of health interventions to achieve UHC,many of which are SRHR-related interventions. The mantra should be “there is no UHCwithout SRHR.” In addition, donors should better integrate and more efficiently use theirresources across HIV and SRHR.3. onors should always make clear if their newly announced commitments include additionalDfunding. To improve accountability and transparency, donors should be clear as to whethertheir commitments are actually new and additional, and how they relate to their previouscommitments.4. Political leadership for SRHR at the country level needs to be strengthened. For donor anddomestic investments in SRHR to be effective, there must be strong national political commitment to openly discuss SRHR issues, to advocate for comprehensive evidence-basedSRHR interventions, and to fight gender-based discrimination. Political leaders can raiseawareness among their governments about the high cost-effectiveness of investing in healthand SRHR, and the large health, social, and economic returns that could result from increased domestic spending on SRHR.5. ountries need to prioritize health, including SRHR, in their domestic budgets. Although theCcurrent economic outlook is less positive than two years ago, many LICs and MICs are stillprojected to experience substantial economic growth in the next decade. While these countries will increasingly be able to reduce their dependence on donor support and financetheir health goals through domestic resources, economic growth alone will be insufficient;countries will need to make the decision to explicitly prioritize health within national budgets. In addition, countries need to reduce spending inefficiencies to avoid wasting resourcesfor health.Funding for sexual and reproductive health and rights in low- and middle-income countries: threats, outlook and opportunities5
1IntroductionSexual and reproductive health and rights(SRHR) are essential for sustainabledevelopment and the realization of the2030 Agenda for Sustainable Development.Sexual and reproductive health – definedby the Guttmacher-Lancet Commission as“a state of physical, emotional, mental, andsocial wellbeing in relation to all aspects ofsexuality and reproduction, not merely theabsence of disease, dysfunction, or infirmity”– is dependent on the realization of sexual andreproductive rights, based on the principlesof human rights. 7 The Guttmacher-LancetCommission calls for expanded access toan essential, integrated package of sexualand reproductive health interventions, madeavailable without causing financial hardship(Annex 1). This is consistent with WHOrecommended interventions and the principlesof universal health coverage (UHC).8The Guttmacher-Lancet Commissionfound that meeting the unmet need forcontraception for 214 million women indeveloping regions would avert an additional67 million unintended pregnancies in 2017.If combined with full care for pregnant womenand newborns, this reduction in unplannedpregnancies would reduce maternal deathsby 73% (from 308,000 to 84,000) andnewborn deaths by 80%, from 2.7 million toabout 538,000 (please refer to Annex 2 foralternative impact estimates on the benefitsof SRHR conducted by the Disease ControlPriorities Project, DCP3). In addition, theGuttmacher-Lancet Commission highlightedthe social and economic benefits of investingin SRHR. Declines in fertility contribute overthe long-term to the demographic dividend– that is, “accelerated economic growth anddevelopment that arises from a change in theage structure of the population.”96The need for sustainableSRHR financingDespite the substantial benefits of investingin SRHR, progress is stalled in part by alack of resources. The Guttmacher-LancetCommission estimates that a minimum globalinvestment of US 54 billion (about US 9per capita annually) is needed to addressthe unmet need for contraceptive, abortion,maternal, and newborn health services inlow-income countries (LICs) and middleincome countries (MICs). Although mobilizingsufficient and sustainable domestic financingis essential, finance from international donorsand development partners is also important forcountries with insufficient resources.Political threats toSRHR fundingA major challenge to sufficient levels offinance is weak political will for SRHR in manycountries. For example, anti-abortion advocacyorganizations are active worldwide, across theUnited States (US) and Europe, as well asin many low- and middle-income countries,including in Africa, Latin America, and theCaribbean.As the largest bilateral funder of global health,anti-abortion policies in the US are feltworldwide. In January 2017, four days aftertaking office, President Donald Trump signedan executive order to reinstate and expand theMexico City policy, also known as the globalgag rule and renamed the Protecting Life inGlobal Health Assistance policy (PLGHA).10Originally created in 1984 under the RonaldReagan administration to restrict abortion,the Mexico City policy has been rescindedand reinstated by presidential administrationsalong party lines ever since. 11 In the past,the policy required foreign non-governmentalorganizations (NGOs) that receive USFunding for sexual and reproductive health and rights in low- and middle-income countries: threats, outlook and opportunities
government funding for family planning tocertify that they will not “perform or activelypromote abortion as a method of familyplanning,” using funds from any source. Underthe Trump administration’s PLGHA, the policyapplies to the majority of US bilateral globalhealth funding, including for HIV, maternaland child health, malaria, nutrition, andother programs – the policy could potentiallyaffect US 7.4 billion in global health fundingin 2019, depending on the extent to whichthis funding is provided to foreign NGOs. 12In March 2019, the Trump administrationintroduced new restrictions further prohibitingforeign NGOs from providing any financialsupport to other NGOs that perform or activelypromote abortion.13Although there is no comprehensive analysison the financial impact of the Mexico Citypolicy, significant evidence shows majorglobal SRHR providers face severe fundinglosses (see Annex 3 for the harmful effectsof the Mexico City policy). Many NGOs haverefused to accept US funding in order touphold SRHR and because the provision ofaccess to safe, legal abortion is central totheir mission. The largest global providers ofglobal family planning services, Marie StopesInternational and the International PlannedParenthood Federation (IPPF), both refused tocomply with the policy and as a result sufferfrom a combined funding gap of US 150million through 2020.14,15 In 2017, the Trumpadministration also discounted all funding toUNFPA under the Kemp-Kasten amendment.16Groups that oppose SRHR are expanding theirinfluence worldwide. US-based conservativeorganizations have funded anti-abortioncampaigns worldwide, including in Africa, LatinAmerica, and the Caribbean.17,18,19 Europe hasexperienced a rise in advocacy against SRHRin recent years, backed in part by significantfinancing from US-based conservativeorganizations. Recent analysis finds thatEuropean anti-abortion organizations havespent 2.1 to 3.1 million annually to lobbyor advocate in the European Parliament andother European institutions, and are gaininglegitimacy and access within European Unioninstitutions.20 Legal advocacy organizationshave also filed legal suits in SRHR-relatedcases to many European courts, includingthe European Court of Human Rights. Thischanging landscape could potentially threatenEuropean support for SRHR in domestic andinternational policies.The resistance against SRHR is also taking onglobal dimensions, as was evident at the 74thUnited Nations General Assembly’s High-levelMeeting on UHC. During negotiations of theUHC political declaration, some governmentsopposed the inclusion of SR
Despite the substantial benefits of investing in SRHR, SRHR is a politicized topic in many countries. Anti-abortion advocacy organizations are active worldwide, across the United States (US) and Europe, as well as in many low- and middle-income countries, including in Africa, Latin America, and the
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