Meetings of ECOSOC regional commissions have taken place since mid-2003 to review accomplishments to date in relation to the 1994 ICPD Programme of Action and discuss undone tasks. If those of us working for sexual and reproductive health and rights needed proof that we have achieved something in the past ten years, these roll-calls of governments were it. The US government was not only unsuccessful in its attempts in every meeting to derail the global commitment to the Programme of Action but was practically alone in its stance and forced to accede to the global consensus.
There have been massive achievements in support of women's reproductive health and rights, stretching across the whole of the 20th century, but there is much left to do. Now it's time to talk about plans for the future. A lot of people are worried that the sexual and reproductive health field is in danger of being derailed. Some think it is to do with the influence of rightwing religious bodies, politicians and governments. Some think we have not made our case to the people in power, such as finance ministers and health economists. Some begrudge the success of NGOs working for other health and rights-related issues, such as HIV/AIDS, to get support too. These are all issues, of course, but what is more important are the shifts in global power dynamics and the policies of bilateral and private donors and lending institutions, resulting in changes in the flow of money, money, money. If we in the sexual and reproductive health field want to succeed in our goals, we need to take account of these changes, while standing firm for what we believe in.
This journal issue, devoted to the theme of power, money and autonomy, addresses these issues. There are comprehensive reviews and analyses of the national policies and programmes of Peru, South Africa, Tanzania and Turkey. Except for Tanzania, these papers describe marked progress, in spite of obstacles, setbacks and less speed than might have been hoped for. Two papers look at specific aspects of the issues at national level, one on the feasibility of partnerships between NGOs and government in Mexico, and the other on advocacy strategies in the face of the influence of Catholic church ideology on reproductive health laws and policies in the Philippines.
Still other papers look at issues of power, money and autonomy in relation to policies restricting women's control of their sexuality, their reproductive decisions and their access to health care services. One, by Kaosar Afsana, is about the prohibitive out-of-pocket costs for obstetric care for the poor in Bangladesh, for whom these services may be available but are not affordable. Another, which analyses abortion ratios and sex ratios at birth in one county in Yunnan, China, shows how daughter discrimination not only persists but is increasing in the context of national family planning policies and declining fertility rates, contrary to expectation. Another is about the conflict between traditional images of women in Cambodia and the reality of women's lives in relation to gender equality, sex work and sexual violence, which are now influencing government policy.
Two others, not directly on the theme, address maternal health. Along with Afsana's paper, the one by Julia Hussein et al is one of the most important papers RHM has published on maternal health for some time. It describes a way to measure the extent of skilled attendance at delivery through use of clinical records, in order to advance improvements in delivery care, and finds that the types of skilled attendance essential for clinical decision-making were present in less than 60% of deliveries in the hospital births studied in Ghana. The other describes how poorly some women who experienced neonatal deaths in Indonesia have been treated. A third paper describes a pilot multi-disciplinary education programme for medical students on sexual and reproductive health in Turkey, which hopefully will be scaled up in the coming years. All these papers illustrate how far medical and midwifery education still have to travel in many countries before quality of care can be said to be achieved. Still another paper, reprinted from the BMJ, discusses the lessons for prescribing policies as a consequence of newly emerging data on the health risks of hormone replacement therapy, and the power of pharmaceutical companies to influence such policies.
Money, money, money
Only a few papers address the question of what donors and lending institutions are doing in the field and the consequences for NGOs, governments and work at national level. Three of these lead off this issue. Perhaps not surprisingly, the authors of two of the three papers sit in a private foundation and an international lending institution, respectively. Barbara Klugman calls for a focus on implementation of services within public health and education systems, since these are used by the vast majority of people needing health care; for monitoring of public sector spending; and for advocacy and community organisation to enable shifts in public understanding of sexual and reproductive rights.
Abdo Yazbeck urges sexual and reproductive health advocates to convince health economists of the feasibility of implementing sexual and reproductive health and rights by preparing properly costed national programme plans, starting from existing infrastructure and human resources. He's absolutely right, this is crucial and should be a high priority for every country.
But costing must be followed by spending. Maternal mortality, about which there is presumably no one left to convince, is a case in point. Clearly, the first order of attention is functioning district hospitals with comprehensive emergency obstetric care, skilled midwives and functioning referral systems. Equally obvious is that safe abortions would reduce deaths by up to 50% in many Latin American countries and up to 15–30% elsewhere, and that the same money used for treating complications from dangerous abortions, often in tertiary facilities, would go a long way towards paying for safe abortion services at primary level. Yet it is 18 years since the first Safe Motherhood initiative was launched by WHO, and even now the International Journal of Gynecology and Obstetrics is publishing basic articles on the lack of emergency transport, the lack of drugs for treating hypertensive disorders, and the fact that sepsis and haemorrhage are major killers.Footnote* Why? Because reducing maternal deaths costs money and is political.
The third paper about funding, by Caroline Halmshaw and Kate Hawkins, is about the capacity of NGOs, community-based organisations (CBOs) and governments to ensure that the influx of HIV/AIDS funds at national level is able to have a significant effect on the HIV epidemic and people's lives, which depends on absorptive capacity at country level. A fourth paper is a critique of the US Global Gag Rule, which bans funding for NGOs in developing countries who provide or advocate for safe abortion care. This paper rightly condemns this nefarious policy as an illegitimate use of donor power, not only because of its negative public health impact but also because it “gags” free speech. Indeed, I would go further and say it is being used to control the sexual and reproductive health policies of other countries and limit NGO autonomy and influence in those countries, thankfully often not successfully.
However, there is more to discuss on the subject of funding than these few papers could possibly cover, and the reason there are not more papers on this topic in this issue seems to be because many of the people who might have written a paper on funding matters are working for “client governments”Footnote* or NGOs and were too nervous to put pen to paper, even with the offer of anonymity. Hence, I will report here what I have been told are problems or have heard reported in meetings, seen happening to others or experienced myself, at the risk of it being labelled “anecdotal”.
Power, power, power
Donors have played a progressive role in all sorts of ways in the past few decades, and among much else, can claim a great deal of credit for starting to make the Cairo agenda happen. Compared to ten years ago, however, there has been an almost complete turnover of who is working in donor agencies, who is in government in key countries and the paradigms of development policy. The consequences of the World Bank's coup of occupying centre stage in determining international health policy, effectively sidelining the World Health Organization, have also been substantial.
One of the problems many people in the field are concerned about is that donors and lenders are changing their policies too often, even before the last policy has been given time to work, which ends up forcing governments and NGOs to do the same. But social and political change moves at a slow pace, and this is a crucial dilemma. Some years back, donors got fed up with corruption and lack of political commitment (or lack of openness to donor policies) on the part of many developing country governments, so they gave a lot of money to NGOs in the field, particularly those offering services such as family planning. Not surprisingly, even the largest NGOs, could not replace government action. Now, the pendulum has swung too far in the other direction. Today, many donors say they cannot afford to fund “projects” or “small” NGOs (whose outreach may be national) anymore, and almost all their money is going to governments, UN agencies and so-called international NGOs.Footnote†
Among European donors, money to governments has mainly gone to the health sector and other sectors as a whole (the sector-wide approach). Now, policy has changed once more and European bilateral money is mostly going into the national budgets of countries (budget support), centralising control of spending in finance ministries. Thus does Yazbeck advise us to start lobbying this new set of stakeholders, who may as yet know little about what is needed to implement sexual and reproductive health programmes. The US government, on the other hand, has remained firmly on the path of vertical funding strategies, to which it has now added a range of fundamentalist-inspired restrictions on how and by whom its funds can be spent. Intermediary funding bodies such as the Global Fund to Fight AIDS, TB and Malaria and private donors such as the Bill & Melinda Gates Foundation are promoting vertical programme agendas as well.
Sometimes donors and lenders, and in some cases the recipients of their money, seem to see development aid and loans primarily as a public relations exercise, and don't actually care if the money is well spent or not. Sometimes funding works in the same way as an oak tree creates a forest. A full-grown oak drops hundreds of acorns each year, and every year one or two of the acorns may grow into trees. The rest serve to fertilise the soil. Do donors and lenders take this view of all the millions and billions they have handed out? Or are they doing it because the return on their investment, which includes profitable contracts for their own consultannts and corporations, is actually greater than the benefit to the recipients? This last is one of several reasons why the gap between rich and poor countries is growing.
Today, given the dominance of international “neo-liberal” economic and trade policies, which in donor countries may conflict with development policy, it seems doubtful whether the achievement of development, “health for all” or the elimination of poverty will take place through development aid, let alone international loans. The General Agreement on Trade in Services (GATS) and the complex interaction of World Trade Organization regulations with other laws are being used by those with corporate global power to reduce national autonomy over public policy. The hegemony of policies to put health care and other public services, as forms of trade, into the hands of profit-making companies, and to remove from governments the responsibility for providing these services, by reducing their role to “stewardship”, creates further conflicts of interest (see Round Up Law and Policy). In addition, the Bush-dominated world is afflicted by profoundly anti-democratic, power-seeking and vengeful behaviour on the part of both the most and the least powerful, in the midst of which it is hard to figure out how to keep public health and welfare on the agenda at all. Maintaining a belief in the importance of working for sexual and reproductive health and rights requires an act of faith in this atmosphere.
Autonomy, autonomy, autonomy
In this context, in spite of all the funding developing country governments and NGOs have received in the past decades, sexual and reproductive health programmes are still not functioning well or at all, and many pilot and introductory programmes have been stopped or not scaled up to national level. NGOs, particularly women's NGOs, remain least able to do something to change this state of affairs.
The ICPD Programme of Action promoted the idea of partnerships between donors, governments and NGOs to bring its goals to fruition. Many serious efforts have been made to initiate and implement such partnerships, with varying degrees of success. Jesica Gómez-Jauregui's paper on Mexico raises pertinent questions about the feasibility of partnerships between profoundly unequal players, however. In the 1980s, the women's health and rights movements consisted primarily of unfunded, voluntary groups whose power derived both from their grassroots base and their freedom to formulate and make demands and critique existing policies and programmes without self-censorship. Today, the sexual and reproductive health and rights “movement” mainly consists of formally constituted NGOs with paid staff who are dependent on donor and government-provided funds and on fees. In many cases, at least in the north, many are contracted to implement policies and programmes that donors and governments, not the NGOs themselves, have decided are their priorities. Indeed, some NGOs have no set aims or activities of their own choosing. This is not what the ICPD had in mind when it called for partnerships between government and NGOs.
True partnerships would be feasible, Gómez-Jauregui finds, only if there were a more equitable sharing of power on the one hand, and a commitment on the part of governments to ensure NGO autonomy and sustainability, on the other. Halmshaw and Hawkins rightly point out, however, that if donors are increasingly going to use governments as intermediaries to fund NGOs and other civil society organisations, which seems to be happening with the influx of HIV/AIDS money, the capacity of developing country governments to disburse funds effectively needs serious improvement. Otherwise, they warn, there is a danger that “home-grown” or indigenous responses will be replaced with solutions imported from the centres of power. Indeed, this scenario is already entrenched through the domination of international NGOs in much of the sexual and reproductive health work in the global south.
NGOs, both north and south, are not secure financially because donors and governments only give them short-term grants and contracts, sometimes only for a few months, usually only for a year or three years, and NGOs are secure only so long as someone is willing to keep funding them. Whole NGOs, whole university research programmes, indeed whole government-run programmes, have not been re-funded and had to be shut down, sometimes overnight, often unconnected to the need for the services they were providing or the quality of the work they were doing. This can occur due to a shift in policy, or because a new political party or minister is in government, or because the directors or a new senior staff person of a donor agency want to take a different tack, fund something new. The best funders give several years' notice and tie-off grants; the worst give one month's notice and nothing more. Mostly, there is no appeal.
A growing number of colleagues are expressing grave concern that far from being made partners to achieve the ICPD goals, many NGOs are being pushed aside and treated as if they and their work were expandable. Here is a list of some of the ways this is happening:
International NGOs may act as proxies for their governments through their offices in developing countries, trying to influence if not direct the policies and work on the ground in those countries. Like their governments and international agencies, they are hiring many of the good staff who may have been trained by indigenous NGOs, offering them salaries and benefits that indigenous, often under-funded NGOs cannot match. Thus, indigenous NGOs may never achieve the technical expertise and capacity necessary to reach their goals and contribute to national development. Worse, they may be the first to be de-funded.
Most donors who are still funding NGOs are tending to move their funding to very large NGOs because, they say, they no longer have the staff or the time to monitor “small” NGOs or their projects. In any case they believe that large NGOs will have a bigger impact and may act as intermediaries and disburse small grants on their behalf. This too may end up preventing “home-grown solutions” and capacity-building of southern NGOs in favour of control by international NGOs from the centres of power.
In line with changing priorities, many funders are cutting their grants for sexual and reproductive health work or withdrawing funding altogether, even if the work being done continues to be needed and is consistently of high quality. Hence, services, advocacy work and other projects, both lonstanding and new, may have to be shut down, leaving demoralised staff and dashing community expectations that any improvement in their situation will be forthcoming.
Neither donors nor governments are ensuring that supplies of commodities such as condoms or contraceptives or essential drugs are being increased in tandem with the success of government services or NGOs to promote their use. This causes shortages and discredits these services in the eyes of those who have been convinced to use them.
Government heads still do not consider it their political and ethical responsibility to require ministers or others in senior government positions to fulfill international agreements that the government has signed on to, whether it is the ICPD Programme of Action or human rights protocols, let alone to maintain existing partnership agreements with NGOs, universities or CBOs. Indeed, they may enter government without even knowing these exist.
Governments made a 20-year commitment to the ICPD Programme of Action, just as they did earlier to primary health care and “health for all”, but some donors have reneged on their commitments before these goals and targets have been achieved. Will they renege in the same way on reaching the Millennium Development Goals, such as reducing maternal deaths and defeating AIDS, TB and malaria?
Some donors are making their own policies and priorities in sexual and reproductive health more important than the policies of the governments and NGOs they fund, and will only consider proposals for work they have decided needs doing. This concentrates far too much power in the hands of the donors to the detriment of other stakeholders and shows profound disregard for their expertise and their stake in what is prioritised.
Donors have been known to stop giving away money at all–even for more than a year–while they reorganise their programmes or revamp their priorities, causing obvious hardship.
When donors have changed their priority areas of work and moved their money accordingly, many NGOs have responded by changing their priorities too, and written proposals that follow the money, thereby trying to keep their jobs and their doors open. This has happened, for instance, with money being moved from sexual and reproductive health to HIV/AIDS. However, most sexual and reproductive health NGOs are not all that competent to work on HIV/AIDS as such, an area they have virtually ignored until the funding started moving there. Their donors may decide to fund them to do AIDS work anyway, because they too may not yet know where the expertise in HIV/AIDS work lies. This not only serves to sideline those with existing expertise in HIV/AIDS work; it can also lead to the sidelining of sexual and reproductive health expertise in both donor agencies and NGOs alike.
A few of the richest donors are putting so much money into the often vertical programmes they want to promote that they are not only distorting the amount of attention those problems receive compared to other problems, but also limiting those involved in addressing the problem to far too few players (sometimes only one organisation or university department). Because these are the bodies with the most money, they are dragging a field that was successfully moving towards integrated and collaborative approaches backwards at breakneck speed, with highly negative consequences.
Many donors and lenders are making increasingly unrealistic demands on NGOs and governments to show “impact”–wanting to see major changes in, say, sexual behaviour or improved population health outcomes in unrealistically short periods of time and with far too few human and other resources. But improving sexual and reproductive health is not like carpet-bombing; it takes time and patience, negotiation and communication.
Donors are grossly overburdening governments and NGOs with complex reporting requirements, sometimes not just once a year but twice or even more. No matter how small the grant, nor for how short a time, they expect lengthy proposals, detailed workplans and checklists of how every possible output and outcome can be monitored and evaluated, and even copies of invoices and receipts. To make matters worse, every donor has a completely different set of requirements for how the information is to be presented and reported. Hence, if an NGO has to apply to ten different donors to get enough funding for one project, it may mean preparing ten different proposals. One African country has 29 major external funders; it is hard to fathom the time and resources that must go into applying, evaluating and reporting to them. Calculations are needed on how much time should reasonably be spent on obtaining and reporting on a one-year project grant, as opposed to three years' money for an entire national health sector, and requirements changed accordingly.
A presentation at a conference in 2003 of the results of an evaluation of six NGOs in a sub-Saharan African country indicated that all six had weak infrastructure, were poorly organised, had a lack of skills and did work that was at best not up to par. This was discouraging, even shocking. But what level of resources had they managed to garner, what skills did they have, how bad were the problems they were addressing, how long ago had they begun, and who had set them up and funded them in the first place? Importantly, there were no other indigenous NGOs around who could take their place. Is the answer to close them down, then, or is it to ensure they can obtain technical support and training that would allow them to do the job they set out to do? This is a complicated issue that needs a great deal of analysis to avoid simplistic answers. Only a solution in which NGOs like these are not left to struggle alone and fall by the wayside is likely to result in progress towards the goals they espoused in the first place.
Looking to the future
What will have changed for the better by 2015 and what will not? External funding is only one piece of the puzzle for developing countries; also important are equitable trade relations and regulation of international capital flows, and at country level increases in job creation, paid employment, education, democratic process and control over corruption, not to mention well-functioning health systems. Without development in the broad sense, sexual and reproductive health are not likely to improve substantially. National autonomy, however, is critical. Until middle- and low-income countries get out from under dependence on external loans and development aid, they will have a hard time sustaining progress.
The previous decade, with health policy dominated by the World Bank, has focused on health sector reform and health economics. It is time to talk about the politics of health again. Health should not be treated as an expendable or saleable commodity nor a consumer item. Health care services are a public good, not a form of trade, and people in need of health care, let alone whole countries, should not be seen as “clients”.Footnote* That governments should assume full responsibility for health care in their countries is above all a political objective. The role of NGOs and other civil society organisations is as collaborating partners. Together, they can better ensure that health care services are available, including for sexual and reproductive health.
However, there is no way that public health services in poorer countries will be able to provide all the health care people need in the near future. A private sector should not only be tolerated but encouraged within clearly defined parameters and regulations, the most important being that it should be strictly non-profit-making and its charges regulated. For example, a sliding scale of charges based on income might be compulsory, so that those who can pay something subsidise those who can pay less or nothing at all. Eventually, if the public health system is consistently prioritised, such NGO services might be absorbed or contracted by the public sector to provide services it cannot yet initiate. For sexual and reproductive health services, NGO service provision has been shown in a number of countries (e.g. Colombia) to be one way to ensure that a greater range of services and a higher quality of care are available to more women and men.
NGOs, women's and community-based organisations have a critical role to play as a source of ideas, as providers of services, as advocates for the health needs and perspectives of their constituencies, and as the political conscience of the field, holding both governments and funders to account. NGOs need a large measure of autonomy to play these roles effectively. If their own governments or external donors demand that they censor themselves or try to force them not to provide services they are committed to providing, they need to find alternative sources of funding and refuse to comply. Censorship by the US government with the Global Gag Rule has been so successful that they are now using similar restrictions in funding HIV/AIDS work to demolish support for sexual rights, the rights of sex workers and condom promotion. If such censorship continues to be allowed to silence even part of the NGO community, the autonomy of the NGO community as a whole will be fatally compromised.
Dialogue between funders and funded, to confront these problems head-on, is badly needed. A greater commitment from donors is needed based on the recognition that improving sexual and reproductive health and rights globally means staying in for the long haul, given the slow pace of change. It also implies greater commitment to partnerships across the field as well, in which capacity-building of autonomous NGOs is prioritised, especially in the global south.
Implementation is the keyword for all stakeholders in the sexual and reproductive health field in the coming ten years. Country case studies along the lines of those in this journal issue may help countries to review progress to date and discuss future needs. Papers in this issue illustrate that in order for sexual and reproductive health care to be integrated into national health systems and budgets, properly costed, realistic programme plans are needed, based on sound epidemiological data. Monitoring and evaluation of the work of both governments and NGOs should be done to ensure that what should be done is being done, and being done as well as possible. However, monitoring and evaluation should not be make-work activities designed primarily to satisfy funders, or loaded with unreasonable demands to show changes that are impossible to show. Mechanisms to hold donors to account, which address and prevent the negative consequences of funding policies and processes, also need to be developed.
The purpose of projects and pilot programmes, if they work well, is to be scaled up. Funding should never have supported them as ends in themselves; instead, proposals should always have been for the longer term and included the bigger picture. Providers of sexual and reproductive health care must be better enabled to provide skilled care, through long-term funding for education and training. Like those working in NGOs and CBOs, providers also need decent pay and conditions, and access to services. Thus, those who are pregnant need good maternal health care, family planning and abortion services, and those who are HIV-positive need treatment and care in order to be able to stay healthy and in their jobs.
A major accomplishment of the past decade is that sexual and reproductive health and rights are no longer marginalised issues. With mainstreaming, however, competition and control by the more powerful players in the pursuit of money and resources, and with it the undue exercise of power and influence, may prevent or destroy efforts at cooperation and partnership, with negative consequences for all concerned. Now, more than ever before, dialogue on how funding is spent and equitable ways of working together are needed amongst all stakeholders. Autonomous women's health and rights NGOs, though they may be the smallest and least powerful players in the field, are needed as much as ever to take their place alongside those working in health care, in government and in other civil society organisations to make sexual and reproductive health and rights a reality.
RHM's impact factor
The ISI Impact Factor figures released in June 2004 showed that RHM has doubled its impact factor from 0.515 to 1.113. Hopefully that means our impact in the world has doubled too!
Figure 1 Karamoja, Uganda 2002
Acknowledgements
Many thanks to Jane Cottingham, Marianne Haslegrave, Rosalind Petchesky and Barbara Klugman for comments on a previous draft and to Frances Kissling for discussion of some of these issues.
Notes
* See IJOG 2004;85(11/Supplement).
* Yazbeck uses this term in his paper for developing country governments who accept outside funding and loans. This is telling.
† The UN is international because it consists of autonomous members from all over the world who meet and jointly determine its policies. With few exceptions, most international NGOs, on the other hand, are based in donor countries and are run primarily by people from those countries; some are international only in that they open offices in developing countries and hire staff to implement their policies in those countries. While democracy in the UN is often illusory, the autonomy of satellite offices of international NGOs may be equaly so.
* Anyone who has ever observed, treated or experienced serious illness knows what a profound misnomer this is.