From Vision to Architecture: Three Questions to Guide the Global Family Planning Movement Towards 2030

The start of 2020 marks a critical juncture for Family Planning 2020 (FP2020) and the broader family planning community to chart a way forward for the next chapter. With the initiative’s original 2020 goal now out of reach, the Beyond 2020 Vision (developed last year following extensive consultation) will help shape a formal process to incorporate lessons learned, revisit FP2020’s structure and functions, and anticipate future needs towards the 2030 SDG milestone of universal family planning access. We’ll be watching to see how the Vision drives the design of the “FP2030” architecture and its key functions—and whether it includes sufficient authorities to meet the community’s expectations. (Together with our colleague Amanda Glassman, we shared initial ideas in this CGD Note last May.)

Here are three central questions we hope will be top of mind for the Core Partners and broader family planning community as these critical next steps in the process get underway.

1. Will new players join the original Core Partners?

The four Core Partners (the Bill & Melinda Gates Foundation, DFID, UNFPA, and USAID) contribute three central strengths: technical expertise, funding, and influence. But as Universal Health Coverage (UHC) gains momentum, the community needs to involve a broader group of stakeholders to entrench family planning within primary health care as a centerpiece of both health and development goals. As the world shifts towards more integrated approaches across reproductive, maternal, newborn, child, and adolescent health and nutrition (RMNCAH-N) programming, the GFF—a fast-expanding financing platform—is an obvious candidate for closer mutual collaboration. Both GFF and FP2030 should seize the opportunity to align countries’ investment cases with FP costed implementation plans and prioritize cost-effective family planning within the RMNCAH-N agenda. Since the GFF is not expected to fill the entire estimated $33.3 billion annual global financing gap for RMNCAH-N, the GFF should likewise be eager to learn from FP2020’s experiences in eligible countries, leverage increased resources for family planning, and achieve efficiencies through improved coordination.

Beyond the GFF, FP2030 should consider expanding the club of bilateral donors. Bilateral funding, as measured by expenditures, was up about 19 percent in 2018, reaching its highest level since tracking began (see Figure 1). While the US remains the largest funder of international family planning—contributing 42 percent of bilateral donor expenditures in 2018—much of this increase is due to delayed programming of US funds from previous years. (Congressional appropriations for family planning have not increased.) But several other bilateral donors have increased budget commitments and expenditures above prior years, including Canada, Denmark, Germany, the Netherlands, Norway, and the UK. Expansion of the Core Partners group to include new bilateral partners could help drive greater programming alignment and strengthen the breadth of experience, viewpoints, and strategies from which the family planning community can draw.

Figure 1. Donor government bilateral assistance for family planning, 2012-2018

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Source: Family Planning 2020

2. How will the partnership raise and sustain resource flows?

At the Nairobi Summit in November—which marked the 25^th anniversary of the International Conference on Population and Development (ICPD)—UNFPA, Johns Hopkins University, and other partners released an initial projected costing to reach an aspirational goal of zero unmet need for family planning. The proposed total price tag is significant: $68.5 billion in 120 countries between 2019 and 2030, or around $6.2 billion per year; for the 69 FP2020 priority countries, the total projected resource need is $50 billion. But estimated annual funding in 2018 for these countries—including from domestic governments, international donors, and out-of-pocket payments—totaled $3.8 billion (see Figure 2). this would roughly amount to an estimated $8 billion gap over 11 years.

According to UNFPA, donor countries collectively pledged $1 billion and private sector firms agreed to mobilize $8 billion in support of sexual and reproductive health and gender equality programs at the Summit. But it remains unclear how and whether these commitments will materialize, and difficult to distinguish between “new money” and status quo financing flows.

How will FP2030 substantially increase family planning funding—and then sustain higher levels of funding year on year? The designs of other global health mechanisms (e.g., Gavi and the Global Fund) include major fundraising functions and authorities to direct funding across target countries. In contrast, the original FP2020 design lacked any mechanism to raise, harness, or direct funding flows—creating major challenges. This is an opportune moment to rethink the central financing challenge for family planning—especially given the cost and task of reaching and serving the growing number of individuals entering reproductive age will likely exceed those for the 53 million additional women and girls already reached and served since the partnership’s 2012 launch.

Figure 2. Distribution of family planning expenditures in 69 countries by source of funds, 2018

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Source: Family Planning 2020

The staggering financing gap also reinforces that global policy and program goals will increasingly be primarily financed, planned, and executed locally. Many countries already aspire to UHC and are rolling out reforms to ensure their citizens have access to a minimum set of essential health benefits. Incorporating high-quality, equitable family planning services within a Health Benefits Package (HBP) could help maximize universal and sustainable access. Yet, as we heard at the Nairobi Summit side event we co-hosted with PAI, decision-making processes on what to include in HBPs differ in each context and are also driven by a complex underlying political economy. New approaches to HBP development are needed to appropriately weigh client-centered family planning against more cut-and-dry models of preventative and curative care. Stay tuned for more CGD work in this space.

Donors must, in turn, recognize a broader context in which many governments also face transitions and/or co-financing obligations from other global health mechanisms (e.g., Gavi and/or the Global Fund). Given these competing fiscal pressures, family planning donors should consider creating stronger incentive structures for domestic financing, including co-financing requirements, as highlighted by CGD’s Working Group on Alignment in Family Planning.

3. How will the family planning community move towards mutual accountability?

While country commitments have been central to the FP2020 working model, its structure and function did not build in a clear accountability mechanism. (CGD’s Working Group also discussed the need for building better accountability mechanisms for results, through linking data with service provision and outcomes, for example.) As Denmark highlighted during the Summit’s opening ceremony, better lines of accountability are essential to reach global goals. The recent UN report on SRHR in UHC echoes that call, and the Summit’s website links to a list of over 1,200 commitments made by governments, donors, and private sector entities (see Figure 3). So how will FP2030—and the larger set of related entities—hold countries and other stakeholders accountable for delivering against their commitments?

At the summit, we were pleased to hear UNFPA announce it is developing a mechanism to “hold all commitment-makers to account.” As this rhetoric is translated into action, the devil will be in the details. What entity will take on the responsibility and cost of tracking these highly varied set of commitments? How will these structures hold private sector actors accountable? What or whom will decide if commitments have been achieved? Finally, how will this entity link with parallel efforts?

Figure 3. Breakdown of 1,200 commitments made at the Nairobi Summit

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Source: Nairobi Summit 

One such parallel effort—a CSO-led tool called the Motion Tracker methodology—is mentioned in FP2020’s annual report released the day before the Nairobi Summit. This approach, which appears quite labor intensive, includes a six-step process to define each commitment, identify a baseline, and develop indicators to track progress; it is already being used in 10 countries. How will these two approaches link up with each other, ongoing government efforts, the GFF’s processes, and other efforts across bilateral and global health funding entities? Instead of adding to the complexity of the measurement and evaluation ecosystem, now is the time to generate a single clear and consistent results framework and measurement approach to clarify accountability across the entirety of the family planning space.

What we’re watching out for

As the process to define the overarching FP2030 architecture gets underway, there is much in motion. While we hope these questions will be top of mind, we also acknowledge there are no clear, easy answers. That said, we’ll be watching for a continued focus on results; clearly and consistently defined responsibilities and accountability structures; and a healthy balance between maximizing program outcomes and investments to strengthen host governance, capacity, and sustainability. We’ll ask how the new architecture will help streamline the current array of complex, labor-intensive planning and programming exercises in family planning and other related areas. We’ll also take this thinking up a level to understand how the eventual FP2030 architecture might align with the paradigm shift towards UHC and with other global health financing mechanisms. Above all, we’ll be looking for opportunities to apply lessons learned since 2012 and ensure the proposed FP2030 structures, functions, and authorities are fit for purpose over the next decade.