Moving forward to achieve the Sustainable Development Goals: How do we secure sustainable investments for family planning?

Defining the need: Linking needs with budget allocations

In Uruguay, up until 2010 public sector contraceptive procurement appropriations came from funds that remained in the budget towards the end of each year, where if they were unused could be allocated to general revenue for discretionary functions. During the first months of the year, although it was necessary to acquire essential supplies, procurement varied greatly, being limited by lack of budget and fluctuating amounts left from the previous financial year, and forecasting of supplies needed was not possible, leading to overstocking in some cases.

A dramatic change occurred in 2010, with introduction by the Uruguayan Government of a budget line item for contraceptive procurement within the national budget, as well as improvement of the logistics system and to forecasting. The laws that enacted budgetary allocations also made it possible for procurement to be increasingly based on the calculation of estimated need. Although the purchase volume decreased, it was a positive indicator because it reflected the current needs.

Since 2010, Uruguay’s Ministry of Health (MOH) and UNFPA have collaborated to facilitate prequalified health commodity procurement at reduced prices compared with local purchases, through agreements or co-financing agreements. This collaboration has permitted significant cost savings in commodity purchasing. As an example, the single purchase of three commodities resulted in savings of more than US$ 1 million¹⁴.

Defining the financing and system delivery gaps: Building on policy changes, strengthening the health system

In Panama, the MOH developed a strategy to undertake a diagnostic study and plan to address deficiencies in forecasting, procurement, storage, distribution, dispensation and use. The MOH alerted health-care facilities at all levels that information collection and record keeping on health commodities was critical to improving the functioning of the system and the experience of clients. The MOH established distance learning modules on logistics management and maintaining the cold chain, and regional health managers also received capacity-building on forecasting and logistics management. To build ownership and custodial responsibility, the Government financed and managed the process with technical support from external actors, including PAHO/WHO and UNFPA. The decision to apply the process to all health commodities, not just contraceptives, made for a more complex process, but also resulted in a larger impact on health. Improvements have reduced unit costs, made procurement more efficient. One of the innovations was an Internet portal for procurement that is open for public scrutiny, making the process also more transparent. In January 2013, the MOH gained permission to hold reverse auctions through the portal, which allows bidders to compete for sale of commodities at the lowest price¹⁵.

Catalysing an evidence-based tailored package of high-impact and cost-effective strategies required to reach long-term sustainability with domestic resources: building on the reproductive health commodity security national strategy

In 2010, the Government of Mexico¹⁶ initiated revision of the national reproductive health commodity security (RHCS) strategy, while simultaneously conducting a midterm evaluation of the UNFPA country programme. With the participation of other state actors, such as the National Council for Population and the Foreign Ministry, a new technical committee was established that developed an action plan to implement the RHCS strategy across five action areas: (1) coordination of strategic actors; (2) political outreach and advocacy; (3) RHCS capacity-building; (4) research and systematization of evidence; and (5) coordinated procurement. The process was designed to build local ownership and accountability, while transitioning UNFPA’s role from implementer to technical adviser.

The results have included increased and more transparent coordination among different governmental institutions. Federal and state procurement of contraceptives is more efficient and uniform, resulting in significant cost savings. The process has also strengthened the capacity of the National Center for Gender Equality and Reproductive Health (CNEGSR) to coordinate and regulate the roles of other federal and state agencies working on FP in order to maintain a more regular supply across all 32 Mexican states. Savings fluctuated between 34 per cent for injectable hormonal contraception and up to 87 per cent for oral hormonal contraception. Overall savings in procurement reported were 47.73 per cent (USD$ 3.97 million).

Integrating family planning into multisectoral investments

The Central Africa Forest Initiative/Reducing Emissions from Deforestation and Forest Degradation Initiative. In 2013, the Government of Democratic Republic of Congo (DRC) publicly pledged commitment to FP at the Third International Conference on Family Planning in Addis Ababa, Ethiopia¹⁷. Shortly thereafter, the Government launched the National Multisectoral Strategic Plan for Family Planning: 2014–2020¹⁸. For the first time, in 2014 the Government paid US$ 300,000 for contraceptive procurement, and in December 2014, it also pledged an additional $2.5 million during the round-table at the Third National Conference on Repositioning Family Planning. By December 2015, the National Assembly approved a line item of $3.5 million in the national budget and in 2016, the DRC Government disbursed $1 million for the purchase of contraceptives¹⁹.

Examples of major new investments include two 5-year programmes that will extend coverage and reduce the financing gap for contraceptive procurement: the Global Financing Facility for Women, Children and Adolescents (GFF) under World Bank leadership, and the Central Africa Forest Initiative (CAFI)/Reducing Emissions from Deforestation and Forest Degradation (REDD+) through the Norwegian Agency for Development Cooperation (Norad). CAFI/REDD+ is an environmental project that includes an FP component in recognition of the role that population growth plays as one of the drivers of rapid deforestation in the Congo basin²⁰.

Sahel Women’s Empowerment and Demographic Dividend. The Sahel Women’s Empowerment and Demographic Dividend (SWEDD) regional initiative, launched in 2015, the result of a joint response by the United Nations and the World Bank Group, is a response to a call by the presidents of the six Sahel countries: Burkina Faso, Chad, Côte d’Ivoire, Mali, Mauritania and Niger. The overall goal of the project is to accelerate the demographic transition, to spur the demographic dividend, and to reduce gender inequality in the Sahel region.

The project identified three key areas of intervention: the creation of demand for reproductive, maternal and child health and nutrition (RMNCHN) services and commodities through social and behavioural change; access and the availability of RMNCHN services and commodities and qualified health personnel; and the support of policy development tied to the demographic dividend.

As a result of this initiative, a regional supply mechanism to obtain lower pricing for quality reproductive health commodities was developed, as well a financial arrangement that included a financing advance from the World Bank relevant partnerships to support the countries during the project’s design, implementation, and overall governance.

Applying a differentiated country categorization approach with transition models: Coordinated transition to sustainability

In Cambodia, a coordinated transition process was established from 2003 to 2012, conforming a Commodity Security Working Group in 2014. A sustained and consistent advocacy effort to ensure the inclusion of national budget for the procurement of FP commodities began in 2014, ultimately the Government established a budget line in 2015²¹.

Advancing innovative financing models that crowd-in and secure additional domestic resources: Use of catalytic pooled funds

Reproductive health commodities security in Nicaragua²² has been bolstered by a sector-wide approach to the health sector by European and multilateral donors. The participants, including Austria, Finland, Luxembourg, Netherlands, Spain, the World Bank, UNFPA, and the Interamerican Development Bank, agreed to pool their donor resources in the Nicaragua Health Fund (FONDOSALUD)—a consultative, negotiating, and consensus body—in support of the Nicaraguan MOH’s multi-year institutional plan. Donor partner members make recommendations to the MOH’s high level directorate on how to allocate financial resources to different health priorities in the country. They also established common indicators for monitoring health and gender and other social equity outcomes, as well as outputs related to efficiency and effectiveness of the financial performance and technical implementation of the plan.

The international donor community, mainly USAID and UNFPA, supported the Government of Nicaragua’s implementation of strategies for FP and reproductive health framed within Integrated Model of Primary Health Care (MOSAFC). One of the most important contributions was strengthening of health sector institutions through implementation of the contraceptive security strategy, which enabled wider use of modern contraceptive methods. To achieve the RHCS objective, donor partners financed the acquisition of contraceptives on behalf of the MOH. Beginning in 2007, USAID initiated a gradual reduction in contraceptive donations to the public sector and ceased making donations in 2009.

With the reduction of contraceptive donations from the international donor community, UNFPA increased advocacy efforts in various areas, among them the Health Sector Roundtable and FONSALUD, so that the Government would increase public funding for the purchase of modern contraceptives.

The importance of including the FONSALUD indicators is that they commit the MOH to monitor and track progress even though funds deposited through FONSALUD do not directly support each of the indicators. Progress is reported each year in the Annual Management Report. This has contributed to the increase in political and financial commitment for RHCS, which is evidenced by the increase in assignation of public funding for procurement of modern contraceptives.

This good practice provides a model for: (1) sustaining improvements made in the health system, such as the health commodities logistics system; and (2) ensuring the MOH is held accountable for improving citizen’s health through the monitoring of common indicators. The collaborative effort has contributed to increasing the Nicaraguan Government’s political and financial commitments to reproductive health commodities security (contraceptives), as evidenced by the increase in the Government’s commitment of resources for health from US$ 227,500 in 2009 to $ 742,173 in 2013.

Similarly, faced with the end of donor support for contraceptives in Bolivia²³, the MOH needed to generate resources to sell and purchase adequate supplies. In 2010, the MOH issued a ministerial resolution authorizing the transfer of UNFPA donated contraceptives to the Health Care Supplies Central Authority (CEASS) so that it could generate sufficient capital for a new revolving fund that would be used exclusively for the purchase of contraceptives. The authorization permitted transfers to CEASS so that it could monetize supplies through the Maternal and Child Health Universal Insurance Scheme (SUMI) to serve as start-up capital in a revolving fund dedicated for procurement of contraceptives. The dedicated contraceptive fund requires that municipal governments also establish a dedicated budget line item for the purchase of contraceptives. This new system allows for purchasing contraceptive commodities at scale, thus lowering prices, and ensuring the quality of the products through CEASS.

To undertake this ambitious strategy, the MOH partnered with the Departmental Health Services, social groups representing different sectors of Bolivian society, and municipal governments. The President issued a supreme decree allowing CEASS to solicit international bids for contraceptives directly. CEASS realized the first autonomous purchase at the end of 2014, which also allowed them to expand the range of contraceptive options available in Bolivia by including the female condom, emergency contraception and implants.

Continuing challenges include the need to strengthen the procurement skills of municipal governments, and to make the Bolivian population aware of the more reliable and greater variety of supply available in health services, which will hopefully contribute to increasing demand and satisfaction.

Increasing domestic resource mobilization through innovative financing, securing expenditure of budget allocation

In 2005, the Universal and Equitable Access to Family Planning Services Law and its Integration in the National Reproductive Health Program in Guatemala ushered in a number of policy, regulatory, and administrative changes to reproductive health services. It guaranteed all Guatemalans access to contraceptives as a means of reducing maternal mortality. It created a commission comprising representatives of the Government, civil society, and universities to ensure that all health facilities, including hospitals have reproductive health services. The Law requires the Ministry of Education to provide all school-age children, beginning in primary school, with sexuality education. The law also guaranteed a process to buy, store and distribute modern contraceptives, along with a system for monitoring and evaluating its implementation. The law amended a previous law that allocated 15 per cent of alcohol taxes for the support of reproductive health and FP programmes so that 30 per cent of the allocation is earmarked for the purchase of contraceptives (Reyes, de la Cruz and Marin 2013). The law also ensured access to reproductive services by adolescents. Between 2002 and 2009, the contraceptive prevalence rate (CPR) increased from 43.3 per cent to 54.1 per cent, and nearly doubled from 23.8 per cent to 40.2 per cent for indigenous women; and unmet need for FP fell from 27 per cent to 20.8 per cent in the same period.

However, this example also illustrates that securing funds is not always sufficient to ensure they are used for the intended expenditure: in Guatemala, between 2012 and 2015 only 64 per cent of funds earmarked for FP and reproductive health were executed.

Negotiated accountability frameworks such as country compacts situated within national oversight mechanisms that detail commitments of all actors

Capitalizing on international commitments. In Sierra Leone, UNFPA engaged in advocacy efforts with other stakeholders aimed at sensitizing top Government policymakers including the Minister of Finance and the Minister of Health on the need to increase domestic fund allocation and release of funds for FP. Specifically, during the 2017 Family Planning Summit, through these advocacy efforts, the Government committed to using Le1 billion (US$136,054) for the domestic procurement of FP commodities out of a total of Le17 billion ($2,312,925; some 5.8 per cent) allocated for the procurement of drugs and supplies. The Government also committed to diversify its resource base for FP through providing a budget line and allocating 1 per cent of the health budget. In 2016, spending on FP from the national health budget was 1.28 per cent.

Later in 2017, UNFPA mobilized domestic resources through the DFID State Level Programme and committed US$700,000 to procure FP commodities for the national FP programme. This amount, complemented the resources provided through UNFPA Supplies, resulting in a UNFPA total donation of reproductive health commodities in 2017 of approximately $3 million.

Strengthening knowledge management systems and practices to ensure policy and programme-relevant information are generated and used for decision-making

Making the case for increased domestic resource mobilization through evidence generation. In Myanmar, the increase in domestic commitment follows advocacy using data on the financial gap for FP, focusing on the Ministry of Health and Sports UNFPA presented findings from the Netherlands Interdisciplinary Demographic Institute survey on FP spending in Myanmar compared against the FP costed implementation plan: as an FP2020 commitment-making country, Myanmar’s expenditure on family planning from government domestic budget is reported annually. Subsequently, the Government increased its budget for procurement of contraceptives by a factor of five. This increase is noteworthy in a country that allocates only 3.65 per cent of its total budget to health, which is very low by global and regional standards. Most households must pay out-of-pocket for health.

Domestic funding for contraceptive procurement in Myanmar increased fivefold in 2017. The national budget allocation rose from US$0.56 million in 2015/16 to $2.8 million in 2016/17. As part of the UNFPA Transition and Sustainability Strategy, funding to Myanmar decreased somewhat from $1.6 million in 2016 to $1.3 million in 2017. UNFPA Supplies also provided an additional $1 million in 2016 for a special initiative to procure contraceptive implants.

A similar approach has been used in Mongolia following a series of assessments showing that during 2016–2020, expenditures on contraceptive commodities should reach an overall amount of US$2.33 million. The costs of spending will be offset greatly by the returns: this investment is estimated to generate savings of US$7.33 million in averted health-care costs in 2017–2020²⁴.