Family Planning Summit Raises Much-Needed Funds. Now It’s Time for Donors to Stop Being Polite and Start Getting Real.

This past Tuesday, I attended the London Family Planning Summit, a high-level and high-profile gathering co-hosted by the United Kingdom Department for International Development (DFID), the Bill & Melinda Gates Foundation, and UNFPA with the goal of raising financial and political support for international efforts to expand contraceptive access to women and girls living in low- and middle-income countries. This follow-on event comes five years to the day after the original 2012 London Summit kicked off the global FP2020 movement, aiming to reach an additional 120 million women and girls with modern contraception by 2020. Watching the summit, one might understandably be overcome with a sensation of déjà vu: same issue, same co-hosts, same location, same hopeful tone, and same basic program (advocacy mixed with financial and programmatic pledging). But context is everything—and the summit’s optimistic tenor at times felt dissonant given the slower than hoped for progress over the past five years and the deep perils of the current political moment. With significant new money raised for the cause—an important accomplishment given the uncertainty around sustained US funding and the reinstatement of the Mexico City Policy—it’s now time for donors to get serious about optimizing the efficiency, impact, and sustainability of family planning programs.

How much did donors commit? A lot

First, the good news: the summit attracted meaningful new financial commitments that will be genuinely helpful in the years ahead. I’ve done my best to compile a quick and dirty “cheat sheet” of financial donor government, foundation, and private sector commitments of >US$1 million (see below). The cheat sheet is based on media reports, my own observation, and the online commitment tracker. But it can be quite difficult to distinguish “new money” from existing commitments, or to parse whether NGOs are double-counting the contributions of their donors.

By my count (involving a number of guesses and judgment calls), the summit resulted in about $870 million of truly new donor commitments, plus about $340 million that had already been announced or allocated in some form, and additional commitments from FP2020 focus countries for domestic spending. The biggest chunks of donor money come from the Gates Foundation (an increase of $375 million, or 60 percent over their already very substantial baseline spending through 2020); the United Kingdom (an extra £45 million per year through 2022); and Canada (US$188 million through 2020 from its previously announced Can$650 commitment to sexual and reproductive health). A number of donors committed only for 2017, and yet others indicated that further commitments are likely to be on the way, so overall totals could still rise. That’s a very significant sum of donor money, particularly on top of many donors’ substantial baseline contributions. (Again, I emphasize these figures are very rough estimates.)

Donor commitments at the London Family Planning Summit >US$1 million

Now it’s time to put the money to work

But with the successful rah-rah moment now behind us, it’s time for donors to get real about disappointing progress to date, ongoing financial and policy challenges, and the uncertainty of US financial support. Many of these issues should be familiar to anyone in the field, but to briefly recap: as of the 2016 midpoint, FP2020 reported that 30.2 million additional women and girls were using modern contraception compared to the 2012 baseline—6.2 million more than historical trends would predict, but 19.2 million below hoped for progress. A number of committing focus countries have not made good on their financial commitments from the original summit, even as they recommit this week. In most low- and middle-income countries, national or subnational government funding represents just a tiny sliver of the family planning funding base. FP2020 as a mechanism has struggled to define its identity and balance competing demands for advocacy, measurement, accountability, and technical support. Donor countries have found their aid budgets stressed by shifting political winds and the refugee crisis (though the latter issue appears to be abating at least in some countries). The Trump administration has reinstated the Mexico City Policy, stripping funding from a number of leading family planning providers. And although the hot-off-the-press draft House omnibus suggests only modest cuts to the US family planning budget for FY2018 (in contrast to the administration’s requested program elimination), the uncertainty means that the US is no longer a reliable partner to fund the recurrent costs of service delivery and commodity procurement.

The time is ripe to move beyond feel-good rhetoric and to confront these challenges head-on. Last year, working with the FP2020 partners, we issued a report with recommendations for donors to improve the efficiency, effectiveness, and sustainability of their investments—ideas that have taken on new urgency in the current climate. You can read the full report here, but for now I would highlight two under-examined areas:

1. Create better incentives for country co-financing. Too many countries are almost entirely dependent on donor funding for contraceptive commodities and service delivery—and that means that women and girls are deeply vulnerable to the ebbs and flows of donor countries’ politics. If the US funding faucet were to turn off, about 10 million women would lose access to contraceptives in low-income countries alone. Real country buy-in means that countries have their own fiscal skin in the game. Instead of pushing ministries of health to cough up funds based on rhetorical pressure alone, it’s past time for USAID and UNFPA Supplies to require co-financing for contraceptive donations, drawing from the GAVI model for vaccines. The copays could be extremely small at first, then gradually increase as countries grow wealthier, helping incentivize investment.
    
2. Ensure family planning is included and delivered effectively as part of health benefits packages. As universal health coverage has risen on the international agenda, many low- and middle-income countries are defining explicit health benefits packages as entitlements for their entire populations and creating health financing strategies to promote their effective delivery. Family planning does appear on most lists of essential health services, but a Marie Stopes International study suggests it is being frequently left off the reimbursable list of services and instead shunted into capitation packages or input-based budgets. Rather than simply pushing for a family planning line item in budgets (that can be removed at any time and does not necessarily create strong incentives for progress), family planning advocacy should be redirected to ensuring inclusion of a rights-based package of family planning commodities and services in the health benefits package, supported by financing arrangements that incentivize high-quality service delivery. In so doing, there are two key challenge. First, family planning may not be cost-effective as a health intervention alone in the most resource-constrained settings, but qualify for inclusion based on rights-based or actuarial criteria. (For more on how to conceptualize these issues, check out my chapter in the forthcoming CGD book on the design of health benefits packages.) Second, countries must design health financing strategies that incentivize high-quality service delivery but avoid undue coercion. There’s an important opportunity here for the family planning community to engage with the broader health financing conversation—an imperative for long-term program sustainability.

I encourage you to read the full report; we also have much to say about moving toward more rigorous resource allocation strategies and increasing accountability for implementers and service providers. The bottom line: the additional resources for family planning are fantastic. Now it’s our responsibility—to the women and girls who need to gain or sustain access to contraception, and to the taxpayers and private individuals funding these efforts—to make sure we use that money as effectively as possible.