Transition from donor aid is no longer a distant prospect, but now a reality that defines the current global health landscape. Many low- and middle-income countries are facing multiple aid transitions, with middle-income countries at particularly high risk of a complex transition landscape. Together with broader development challenges like rising debt levels, these transitions exacerbate budget pressures across the health sector. In recent years, global health mechanisms such as the Global Fund and Gavi have begun to develop and implement transition policies and plans—though mostly in silos—but the family planning community has lagged behind.
This month’s Nairobi Summit, which marked the 25th anniversary of the International Conference on Population and Development (ICPD25), convened country governments, donors, advocates, and other development partners who championed sexual and reproductive health and rights as critical to the Universal Health Coverage (UHC) agenda. While many donors and private sector partners made financial commitments at the conference, research presented there suggests an anticipated $68.5 billion in total resource requirements over the next decade to meet unmet need for family planning in 120 low- and middle-income countries.
Given these projected financing needs, we were hoping to see one issue—which has the potential to stall progress on the family planning (FP) community’s important goals—take a more central role in the discussions: transitions in global health aid and their implications for family planning. Country governments and development partners must contend with the reality of transitions from donor aid and plan strategically to sustain equitable, affordable, and high-quality family planning programs with increased domestic spending. If not managed well, these looming changes could undermine hard-won gains and threaten progress on family planning—a key contributor to advancing health, gender equality, and women’s economic opportunities.
The family planning community must place transition much higher on its agenda and act quickly to prepare for it, especially in the two dozen middle-income countries (MICs) where our previous and ongoing research suggests that transition is likely to happen soon. Reflecting on last week’s conference and our forthcoming research on family planning transitions, this blog highlights some of our key initial takeaways.
Transition from donor aid is the new reality
Many middle-income countries have transitioned or are transitioning away from donor support for family planning, HIV, tuberculosis, malaria, immunization, and polio programs, among others. In the late 1990s and early 2000s, family planning programs in several countries, notably in Latin America and the Caribbean, transitioned from USAID support. Since 2014, more than a dozen countries have seen their funding from Gavi end and over ten countries have had financial support from the Global Fund come to a halt. Indeed, many more will lose eligibility for support in the coming years; for example, eleven countries are projected to see their Global Fund money terminate by 2025. Navigating a smooth and efficient transition from external donor support to national self-sufficiency can be difficult and risky for country governments, particularly when multiple programs experience transition at the same time.
Simultaneous transitions from multiple global health mechanisms are likely to create a fiscal crunch across the health system, with potential risks for access to health services, including family planning
Many low-income and lower-middle-income countries rely heavily on external support for family planning, especially for contraceptive supplies. A sudden, significant drop in donor support for family planning could be especially destabilizing. Large changes in donor assistance for other health program areas beyond family planning will also likely have ripple effects. With global health mechanisms (e.g., Gavi, the Global Polio Eradication Initiative, PEPFAR, and Global Fund) anticipating to draw down funding in dozens of countries over the coming decades, a fiscal crunch for the entire health system is on the horizon. Faced with increasing financial pressures, it is unclear if and how governments will use their own health budgets and health insurance schemes to make up for the shortfalls in areas that have traditionally received significant donor support—including family planning. Beyond the fiscal crunch, our research also suggests that transition creates risks for important health system functions like procurement and supply chains.
Kenya, the host nation for ICPD25, is a good case in point. In recent years, about 60 percent of the $74 million spent annually on family planning has come from donors—a majority from USAID (note, government funding mainly goes toward recurrent expenditures for personnel). Stagnating donor support and decreased government funding following devolution, coupled with the needs of a young and growing population, has left a significant contraceptive funding gap. Projections demonstrate a gap of $14.6 million, or 67 percent of all commodity costs, in the 2019-20 fiscal year.[i] At the same time that Kenya is under pressure to increase domestic family planning investments, it faces rising co-financing obligations and possible reductions in donor support for other health areas, such as HIV and malaria, where external funds currently account for 63 percent and 53 percent of total program expenditures, respectively.
Kenya is not alone. In other countries like Ghana and Bangladesh where donor support is also in transition (and where we are also conducting case studies), the family planning program must similarly compete for scarce domestic resources with other health areas, many of which have powerful lobbies around the world. In these challenging environments, how will governments balance the tough trade-offs as they decide how to allocate domestic resources for programs previously supported by donors—and what is the risk that family planning could lose out?
Governments and family planning donors in transitioning countries are currently ill-prepared to compete with other health programs for scarce resources
Country governments and advocates are less aware about looming transitions and ill-prepared to address the potential implications for family planning, compared to other health areas. Gavi, for example, is helping governments prepare for transition by investing in improvements in vaccine forecasting and procurement, immunization worker training, and vaccine cold chain. Similarly, the Global Fund, UNAIDS, and PEPFAR are supporting “transition and sustainability readiness assessments” and the design and implementation of multi-year action plans in more than 35 countries. Immunization, HIV/AIDS, TB, and malaria policymakers and researchers are also analyzing the successes and shortcomings of past country transition experiences, actively incorporating these lessons into upcoming transition planning. While these donors are taking the initiative to support a smooth transition process, they are still largely being implemented in silos, creating the risk of leaving behind a fragmented health system that may not maximally benefit its population.
To our knowledge, there is no such comparable effort ongoing for family planning. The policies and processes for family planning transition of the main funders, including USAID, DFID, and UNFPA, are not explicitly stated or evenly applied (though, it should be noted that a 2006 technical document outlines USAID’s approach to family planning transition, including trigger indicators to start the process). Overall, the dialogue between donors and national governments on family planning transition is still at a nascent stage.
The FP community needs to step up on transition thinking and action
It is encouraging that expanded financing and integration of FP services in countries’ Universal Health Coverage schemes were two central themes at ICPD25. However, we would like to see country governments, with support from development partners, be much more focused on the realities of transitions in planning the future of their FP programs.
Drawing on our ongoing research, we call for the following actions over the next 2-3 years to better manage transitions from donor aid for family planning:
National family planning policymakers in these countries should coordinate with their colleagues managing transitions in HIV, TB, malaria, vaccination, and other donor-supported programs, as part of larger country strategies on “health aid transition.” Convening—or building on existing—cross-cutting working groups on health transition at the national level presents an important entry point to enable family planning to be managed alongside other simultaneous health transitions.
Governments—especially in the two dozen middle-income countries where transition may be imminent—should take the lead in developing a comprehensive and practical approach to health transition, which includes all major health donors, including those for family planning. For example, this could be informed by integrating transition planning into sector-specific strategic and operational plans.
Key family planning donors (including USAID, DFID, UNFPA, BMGF, and the World Bank/Global Financing Facility) should support country partners as they formulate and implement transition plans. This could include building capacity to develop realistic local cost estimates for family planning to guide planning and budgeting. In the same way that Gavi helps with immunization transition and Global Fund and UNAIDS with HIV transition, family planning donors need to provide dedicated transition-focused technical assistance. (While efforts to drive coordinated support among donors are at nascent stages via the WHO’s Health Financing accelerator, more could be done to build local capacity for a smooth transition).
Key family planning donors should also support the strengthening of cross-cutting systems and processes such as procurement (e.g., product selection and price negotiations), supply chains (e.g., improved harmonization and forecasting capacity), and health information systems. These will be critical to ensure smooth transitions in family planning and other health areas.
If the family planning community doesn’t get ahead of the curve on planning for a sustainable future as other vertical health programs have started to do, it will be to the peril of millions of women and girls, their families, and their communities. Looking ahead, countries and donors need to act quickly and decisively to incorporate family planning into broader transition planning as a critical component of achieving UHC, and thus ensure that family planning remains at the center of global and country agendas for social and economic progress in the coming decades.
Thanks to Kalipso Chalkidou, Felice Apter, and Gabrielle Appleford for feedback.***
[i] CHAI, 2019. Kenya FP Commodity Funding Gap Analysis 2018-2021, May 2019.