In July 2012, world leaders gathered to reaffirm the right of women and girls to make informed and autonomous choices about their reproductive lives. To support the implementation of this right, country governments and donors committed to three actions:
A new partnership to enhance accountability for progress—Family Planning 2020 (FP2020)
An aspirational goal—120 million additional users of voluntary, high-quality family planning services by 2020
$4.6 billion in additional funding, including $2.6 billion from international donors and the private sector
This year, FP2020 reached its midpoint—and an important inflection point. In four years, from the 2012 baseline to July 2016, 30.2 million additional women and girls became users of modern contraception—6.2 million more than would be expected based on historical trends alone. Yet these gains fall short of aspirations, and in mid-2016, the number of additional users was 9.2 million short of that year’s goal. The midpoint of the FP2020 initiative thus offers an opportunity for family planning funders and the FP2020 partnership more broadly to take stock of progress; to reflect on the lessons of the past four years; to refine funding and accountability mechanisms; and to reallocate existing resources for greater impact.
Governments have responsibility, but donors remain majority funders of family planning in many countries.
Primary responsibility for expanding contraceptive access lies with country governments. Nonetheless, donor contributions play an important role—in fact, between 2004 and 2014, donors’ per capita family planning disbursements at the country level were significantly associated with increases in the contraceptive prevalence rate, even after controlling for time-trends, government effectiveness, and per capita income. And in some countries, donors continue to finance the lion’s share of family planning program budgets; almost the entirety of Nigeria’s family planning program was funded by donors in 2015, for example.
Can donors and partners do more to accelerate progress?
With the goal of reaching as many women and girls as possible by 2020 and an eye toward the even more ambitious 2030 Sustainable Development Goals, the Center for Global Development (CGD) convened a working group on donor alignment in family planning in fall 2015—to see how scarce donor resources could go farther to accelerate family planning gains. The working group deliberations, together with original quantitative research and country case studies in Kenya, Nigeria, and Uganda, resulted in a final report, which analyzes the successes and limitations of family planning alignment to date, with a focus on procurement, cross-country and in-country resource allocation, incentives, and accountability mechanisms, and makes recommendations for next steps. This brief summarizes the working group’s key findings and recommendations.
Funding for family planning has grown, but risks are on the horizon. Currency depreciations are affecting the real value of non-US donors’ contributions, political crises are turning donors’ attention away from family planning, and changes in leadership may lead to declines in overall financing or affect its stability in the long term.
In aggregate, allocation of donor resources does not closely track family planning need, measured in different ways. Each donor takes a different approach to cross-country allocation, using different criteria and processes; the resulting “priority country" lists do not necessarily align with each other or the FP2020 list of 69 focus countries. Several countries consistently receive funding well below their relative need: these include Gambia, Guinea-Bissau, Nigeria, and Somalia.
Country-led costed implementation plans (CIP) have set a broad and aspirational direction for countries’ family planning programs, with buy-in from government and civil society. However, most CIPs cannot easily be used as operational documents to optimize resource allocation decisions by country governments, donors, and other funders. At present, most CIPs do not use modelling to set realistic programmatic goals; few reflect funding that is actually available or tie into other plans for the health sector; and many do not set clear priorities to clearly inform the allocation of donor or other funding. Senegal offers an example of a well-designed and well-functioning CIP, with lessons for other countries, but this remains the exception, not the norm.
Alignment of reproductive health commodity purchasing and supply chains has improved substantially since 2012, but the sustainability of parallel supply chains may be at risk given the volatility of aid. UNFPA is one of three major organizations supporting Nigeria’s public sector supply chain, but its Supplies program is currently facing a substantial financing gap.
Countries have few incentives for co-financing and some disincentives to increase domestic investment. As an example, domestic funding for family planning commodities in Kenya ceased following the decentralization process, but that gap was quickly and entirely filled by donors. At the time of writing, domestic funding had not returned to pre-decentralization levels.
Finally, while high-level accountability for progress and results is in place, there is little to connect success or failure to particular streams of funding or service provision, and thus it is difficult to close the accountability loop and learn lessons about what is or is not working. Few programs in the family planning space undergo rigorous independent impact evaluation.
The working group recommends three actions to accelerate progress to FP2020 goals:
Support more strategic and collaborative resource allocation at the country level, building on past successes and existing coordination platforms.
Recommendation 2: Create stronger incentives for greater cofinancing and performance.
Recommendation 3: Enhance accountability and learning across the results chain.
1. Support more strategic and collaborative resource allocation at the country level, building on past successes and existing coordination platforms.
First, FP2020 secretariat and donors should work with countries to strengthen the utility of their CIPs and other planning and resource allocation documents. Technical support for the development of CIPs should help countries to set ambitious but realistic goals for progress using modelling; clearly prioritize activities under different funding scenarios; and ensure that CIPs reflect actual funding streams and programs from donors and government, among other criteria. Second, donors should improve the transparency and predictability of their own funding decisions by sharing timely and detailed data on funding decisions with counterparts at the country level; by increasing transparency about expected resource allocations over a three to four-year time horizon; and by ensuring their actual and planned funding streams are clearly reflected in sector-wide planning documents. Third, donors should move beyond ‘business as usual’ by adopting a more strategic approach to their own resource allocation.
2. Create stronger incentives for greater cofinancing and performance.
At present, donors primarily finance family planning inputs—commodities and NGO salaries/operational costs—with few explicit incentives for their grantees to improve the scale and quality of service delivery. Accordingly, the FP2020 partners should test whether the introduction of incentives—financial and otherwise—can better align efforts and improve co-financing and performance. Such incentives must be carefully designed to ensure respect for the principles of voluntarism and informed choice; for example, incentives should not explicitly reward the number of new family planning users but instead focus on improving measures of access, service quality, and choice. Incentives should be considered across multiple relationships: between donors and recipients; between multiple levels of government (e.g., national and subnational); and between governments or implementing partners and individual facilities. Donors should also test ways to increase government co-financing and reduce the fungibility of family planning assistance, for example by considering stricter co-financing policies, particularly in middle-income countries, or matching fund schemes for commodity purchases.
3. Enhance accountability and learning across the results chain.
First, drawing from experience elsewhere in the health sector, FP2020 funders should enhance accountability for performance among grant recipients by instituting regular independent verification of self-reported progress. Second, FP2020 partners should improve the generation and utilization of evidence to inform resource allocation by requiring that at least a subset of funded programs undergo rigorous independent impact evaluations and taking steps to increase the accessibility and dissemination of existing project evaluations, potentially by creating a shared database and requiring submission of all project evaluations to the common pool. And finally, FP2020 partners should sustain and build upon current efforts to improve tracking and accountability for family planning expenditures.