High-Level Task Force for ICPD, February 2015
Available from: http://icpdtaskforce.org/resources/HLTFFinancingSRHRBrief.pdf
The following bookshelf piece highlights the key messages from this paper. The extracts highlight the core messages from the eight policy considerations with top recommendations from the paper. The full paper provides examples of successful innovations and more detailed evidence, including a full bibliography, informing these recommendations.
Introduction
This document was commissioned by the High-Level Task Force for the International Conference on Population and Development (ICPD)Footnote* to serve as reference and ‘food for thought’ for policymakers, donors, development partners, and civil society advocates working on sexual and reproductive health and rights (SRHR) issues. It may be especially relevant to stakeholders involved in national financial planning and budgeting and related advocacy, as well as the development of new global financing mechanisms related to implementing the Post-2015 Development Agenda.
Context
The Post-2015 Development Agenda will influence policy priorities and resource flows for years to come. The success of the agenda depends not only on the substantive contents, or the “what”, but also the “how”, specifically financing and other means of implementation, such as knowledge and technology transfer, capacity building, improved policy coherence and an enabling environment, as well as the outcome of the Third Financing for Development Conference.
The commitments related to SRHR in the new global framework, as reflected in the Sustainable Development Goals, will require increased and sustained funding to be achieved by the 2030 deadline. This paper puts forth policy considerations to this effect, to help lay the groundwork for implementation and improve resource mobilization at national and global levels.
Smart investment for sustainable development: sexual and reproductive health and rights
SRHR are fundamental human rights, central to eradicating poverty and achieving sustainable development across its social, economic and environmental dimensions. SRHR – which encompass a range of issues, including universal access to SRH services and supplies, comprehensive sexuality education, and ending gender-based violence and harmful practices such as early, child and forced marriage – are fundamental to the ability of all people, especially women, adolescent girls and young people, to lead full, satisfying, healthy and productive lives. With a focus on prevention, investments in SRHR are not only critical to people’s wellbeing and the prosperity and resilience of families, communities and nations, but are also proven to be cost-effective and cost-saving, freeing resources for investment in other development priorities.
Despite the proven returns on investments, underfunding of SRHR persists. This is a contributing factor as to why the core goal of achieving universal access to sexual and reproductive services adopted by 179 governments at the International Conference on Population and Development (ICPD 1994) twenty years ago remains unfulfilled, and why the Millennium Development Goal on improving maternal health (MDG 5) has been among the furthest behind.
The compact adopted by Member States in 1994 stipulated that one third of funding for the ICPD Programme of Action in developing countries would come from overseas development assistance (ODA), and two thirds from domestic resources. Notably, as of 2011, the last year for which data is available, developing countries were covering three quarters of the ICPD package, a large share (62%) of which was financed out-of-pocket by private consumersFootnote† - with alarming implications for equitable access to these preventative and life-saving services. Furthermore, most of these domestic funds are from a few large countries, while many, especially Sub-Saharan African and least developed countries, still face major challenges in mobilizing the required levels of financing.Footnote‡
On the donor side, the bulk of ODA funding for health goes to HIV and AIDS, while support for reproductive health care and family planning fell by half between 2000 and 2010 as a proportion of total ODA for health.Footnote§
Targets in the new agenda should not be misconstrued as the sum total of actions required to fully realize SRHR. The post-2015 era offers stakeholders an opportunity to apply lessons learned and avoid the overly distilled, reductionist and siloed approach to SRHR to which the Millennium Development Goals contributed. This approach engendered parallel, vertical funding streams and programmes for what are actually interrelated priorities -- maternal health, HIV/AIDS, family planning. This skewed funding trends away from integrated SRH service delivery, and excluded the broader agenda of action that transformative progress requires.
SRHR problems are entirely preventable. The costs of inaction – to health, lives, economic productivity and public budgets – far outweigh the costs of the investments required to fulfill SRHR. These investments have multiple high payoffs that will bolster poverty eradication and drive inclusive sustainable development in the post-2015 era and beyond.
Policy considerations & recommendations
| 1) | Develop national financial action plans for SRHR All countries should develop multi-year national action plans for financing SRHR, and ensure the integration of SRHR plans and budgets within broader national health strategies and budgets, as well as within other relevant sectoral plans (i.e. education, gender, youth, etc.). The plans should: a) reflect a holistic approach to SRHR and the actions required to achieve them, b) be developed through a participatory process that involves all relevant government ministries and civil society, especially women’s and youth groups, and c) bring together all donors and development partners to coordinate efforts and avoid duplication. Financing plans should be measurable and transparent, and countries should provide for enhanced public, periodic and independent monitoring and evaluation mechanisms to track how commitments are being met. Plans should be driven by an equity perspective focused on reaching the poorest and most excluded sectors of the population and rural and remote areas of the country, with emphasis on achieving universal access to comprehensive SRH information, education and services, including all the core components (maternal-newborn health, contraception, HIV/AIDS and sexually transmitted infections, treatment for complications of unsafe abortion and safe abortion services), and tailored to the needs and perspectives of all age groups, with particular attention to adolescents and youth. Funding should cover at least an essential-level response to gender-based and sexual violence (with functioning multi-sectoral referrals in place). Financing for collection and analysis of disaggregated data should also be a priority in order to track equitable access and outcomes in relation to SRHR. A holistic approach would also imply budgeting support for national human rights mechanisms charged with protecting SRHR, and overall, ensuring other robust investments for enabling health system strengthening, gender equality and other key areas that particularly influence SRHR outcomes. | ||||
| 2) | Improve tracking of financial resource flows for SRHR States should improve systems for tracking and reporting domestic and international financial flows dedicated to SRHR, and regularly review allocations against expenditures. In the short term, all countries should report total health expenditure and total sexual and reproductive health (SRH) expenditure by financing source, per capita. ‘Compacts’ between governments and all major development partners in a country should be in place that require reporting on externally funded commitments and expenditures, based on an agreed common format. | ||||
| 3) | Reduce fragmentation of donor funding streams Donors and recipient countries should take steps to improve coordination to reduce parallel programming and fragmentation of funding streams for SRHR. The proliferation of new funding initiatives and donors, while very positive, can lead to inefficient resource use, duplication, excessive transaction costs and undue burden on scarce resources, especially human resources. For example, as of 2009, even before several new large-scale initiatives were launched, there were more than 40 health-related bilateral development partners and global initiatives. One global estimate found that the average donor-funded health project left less than half of the available funds for project costs (e.g. infrastructure and equipment, drugs and materials), and that the same health staff may be called to attend a high number of capacity building seminars funded by different donors covering similar topics. A study in Rwanda found that government staff spent three days a year to service each aid mission, with 168 such missions per year, and an estimated 27% of all government and donor resources for health spent on administration. This concern with fragmentation comes at a time when there is increasing attention to investing in strengthening health systems as a whole, and thus to enhancing coordination among donors to fund country-owned health sector strategies. This is the objective, for example, of the International Health Partnership (IHP+), launched in 2007 and which has since grown to 63 partners, including over 50 developing country partners, bilateral donors and international development agencies. However, without dedicated funding initiatives for SRHR, funding for it may become diluted or take a back seat to other health sector priorities. A dedicated financial action plan for SRHR (as described under Recommendation 1) can counter this risk, while the compacts among donors and national stakeholders (as described under Recommendation 2) can reduce overlap, fragmentation and funding gaps for particular issues at the national level. At the global level, as new partnerships and funding mechanisms materialize for implementation of the Post-2015 Development Agenda, such as the Global Financing Facility to Advance Women’s and Children’s Health under the auspices of the World Bank Group, the importance of seizing opportunities to promote strong coordination of funding streams – including to improve comprehensive programming and integrated service delivery from a rights-based approach – cannot be overstated. | ||||
| 4) | Improve efficient use of available resources To more effectively and efficiently employ financial resources allocated to SRHR, investments should be made to strengthen the financial planning and management capacities of relevant government authorities and health personnel. Enhancing financial management skills through training and technology can improve government capacities to overcome the bottlenecks related to logistics, administration, procurement, infrastructure and human resources that impede the ability of a ministry to spend its allocations in a timely manner. […] Countries should also take full advantage of flexibilities in the TRIPS agreement to maximize access to less expensive generic drugs. | ||||
| 5) | Increase mobilisation of domestic public revenue for health, including SRH While a large proportion of SRHR spending comes from domestic sources, a significant portion of this is out-of-pocket expenditures by individuals, implying inequity in access to services based on ability to pay. There is thus a pressing need to maximize fiscal space for health spending, including for SRHR. Opportunities include improved tax collection, excise taxes (e.g. on tobacco or alcohol), earmarking tax revenues (hypothecation), financial transaction taxes, and exploring monetary and debt management policy scenarios that could free up resources for health, including SRHR. | ||||
| 6) | Remove financial barriers to accessing SRH services Countries should allocate sufficient funds to effectively remove financial barriers for people to access SRH services. Out-of-pocket expenditures for health care, including SRH, impoverishes individuals and families. Ideally, countries would provide universal free access to services and eliminate financial barriers at point-of-service delivery. This requires a commitment to a tax-funded budget allocation to ensure the provision of at least a minimum service package on a universal and free basis, of which SRH services must form a core part. | ||||
| 7) | Mobilise new innovative sources of financing and scale up existing ones Various innovative sources of financing have been proposed and in some cases are already being implemented for a number of development priorities, including health. These could be adapted to provide additional funding for SRH. Examples include financial transaction taxes and debt swaps, air ticket levies, carbon taxes, Advanced Market Commitments (whereby donors provide incentives for the development and low-cost sale of products, such as vaccines), or allocations of the IMF’s Special Drawing Rights (which enable developing countries to access hard currency), among others. The Monterrey Consensus on Financing for Development Footnote**recognizes the importance of exploring innovative sources of finance “provided that those sources do not unduly burden developing countries.”Footnote†† They are no substitute for domestic resource mobilization efforts and overseas development assistance, but could leverage important additional resources. | ||||
| 8) | Regulate private sector financing for the provision of SRH services The use of public-private partnerships (PPPs) as a means of financing SRH is on the rise, and in light of growing interest and prominent discussions on PPPs in the context of the Post-2015 Development Agenda, it will be especially important for countries and stakeholders engaging in such partnerships to expressly address the potential risks and shortfalls that can distort public health principles and objectives. Public-private partnerships to finance SRHR, outsource service provision, or advance research and development should be carried out only under strong regulation and stewardship by governments and within an existing context of tax-funded public health care, to ensure equitable access, quality of care and compliance with human rights and ethical standards. This should involve ex ante screening to determine whether private sector partners have a demonstrated commitment to rights- and gender equality-based approaches, have any prior involvement in human rights abuses or corruption, respect tax and other financial obligations, comply with labour and environmental standards, and have no conflicts of interest, for which proper disclosure should be required. Such screening will also help guard against any reputational risks from partnering with for-profit entities with questionable records and that do not satisfy basic standards, particularly relevant for national governments and international and multilateral organizations such as the United Nations entering into global partnerships with the private sector. The decision to enter into PPPs should be taken in a transparent manner with the participation of affected communities, and with safeguards in place against undue influence by for-profit firms with conflicts of interest. The post-2015 era should serve as an opportunity to develop new guidelines and regulations for public-private partnerships, taking into account the principles and good practices under existing international guidelines. | ||||
| 9) | Strengthen monitoring and accountability for fulfilment of financial commitments to SRHR Despite many new initiatives and commitments related to various aspects of SRHR, political will and resources remain inadequate. If the Post-2015 Development Agenda and related human rights obligations are to be met, multi-layered monitoring and accountability systems linking national, regional and global levels must be put in place to track fulfilment of commitments, including financial commitments and resource flows, both from domestic resources and ODA. This should involve mechanisms for public, periodic, independent evaluation of how all actors progress towards meeting their commitments. At national levels, country accountability platforms should be established and strengthened to bring together governments, donors and country stakeholders to provide national coordination and follow-up to SRH financing commitments, based on an integrated SRHR policy framework and programming approach. Public, transparent, measurable national strategies and financial plans as outlined in earlier recommendations can serve as key accountability instruments at national levels. At international level, particularly relevant in the context of the twenty-year review of the ICPD Programme of Action and the implementation of the Post-2015 Development Agenda, and as a complement to other monitoring and reporting mechanisms to be put in place, a global independent expert review group could be established, charged with periodic monitoring and strengthening accountability. | ||||
Notes
* The High-Level Task Force for the International Conference on Population and Development, co-chaired by former Presidents Joaquim Chissano of Mozambique and Tarja Halonen of Finland, is an autonomous group of distinguished representatives from all regions of the world, with records of service in government, parliament, civil society, the private sector and philanthropy. Its mandate centres on the Post-2015 Development Agenda process.
† UNFPA, 2013. Resource flows Report for year 2011.
‡ UN Economic and Social Council, 2013. Flow of financial resources for assisting in the implementation of the Programme of Action of the International Conference on Population and Development. Report of the Secretary General. Commission on Population and Development. Forty-sixth session, 22-26 April 2013, E/CN.9/2013/5.
§ United Nations, 2012a. The Millennium Development Goals Report 2012.
** The Monterrey Consensus is the outcome document of the 2002 International Conference on Financing for Development, which sets out an internationally agreed framework for global development partnership in which all countries commit to take joint actions for poverty reduction.
†† Monterrey Consensus on Financing for Development, 2002. 3 U.N. Doc. A/CONF.198/3, Mar. 22. http://www.un.org/esa/ffd/aconf198-11.pdf.