Yesterday’s family planning summit seems to have mobilized new funding commitments totaling USD 414.5 million between now and 2015. Without going into whether this increased funding will displace spending on other global health and development priorities, no one seems to have mentioned what organization will actually allocate and spend these additional resources.
UNFPA is one option as the United Nations agency charged with implementing supportive programs to achieve sexual and reproductive health outcomes. As part of the Summit, UNFPA has announced it will reallocate its existing resources such that an amount equivalent to 40% of its current funding levels will go to family planning. This is a very positive measure given that only 25% (!) of its current resources go to family planning, and is consistent with a CGD working group’s recommendations to Dr. Osotimehin on the reform of UNFPA. Yet other reforms recommended by the working group --on monitoring and evaluation, transparency and human resource reform-- are still pending, suggesting that a much larger investment via UNFPA may be misplaced at this time or that new funds should be used to leverage more rapid reform.
The World Bank’s Health Results Innovation Trust Fund (HRITF) has also been floated as a vehicle for the increased spending. Established in 2007, this trust fund has just begun to implement and evaluate 20 pilot programs to test supply-side performance-based financing in low-income countries. Yet there are concerns with this option as well. HRITF took 6 years to launch 20 pilots; is this the most efficient modality at our disposal? HRITF has also restricted its interventions to supply-side performance-based payments. Does this make sense for family planning programs? There are certainly many thorny unintended consequences to consider. Paying providers on family planning counseling visits or availability of contraceptives may not have anything to do with impact or quality, while paying out on contraceptive prevalence rates, continuation rates or couple-years of protection is problematic because of the incentives created for long-term method use. Further, NORAD –a major HRITF donor- recently published an evaluation of the Fund that -while encouraging in many respects- is not glowing. Are World Bank-ers ready to oversee direct family planning service delivery projects and their contractors? I’m not sure.
Another alternative is to pump more money through the large international family planning NGOs – International Planned Parenthood Federation, Marie Stopes International, Population Services International, Population Council, Pathfinder, FHI, etc. Yes, ok. But somehow one would like to see more money going directly to governments to provide these essential services. If we do run more money to the big international NGOs, I hope we’ll see more rigorous impact evaluation and total transparency on spending and its uses.
While somewhat unrealistic, I have a better idea – some combination of them all. USAID’s family planning office can plan and oversee the program (the U.S. currently represents more than half of all global spending on family planning) –USAID has a well staffed operation of experts managing contracts for service delivery, data collection, logistics, supply chain, procurement, research and development, with constant oversight from the U.S. Congress on their compliance with informed consent. The international NGOs will do the technical assistance to service delivery and other areas. The UNFPA can procure the contraceptives and build the political consensus. The World Bank can do the impact evaluation.
What do you think? How will donors decide?