Organising and Financing for Sexual and Reproductive Health and Rights

Abstract

This paper is a reflection on some of the successess and challenges that followed in the aftermath of the International Conference on Population and Development (ICPD), Cairo, 1994, and the capacity of civil society and of donors to address them. It is written with two voices–from my experience as an NGO activist for sexual and reproductive rights since the early 1980s and my experience as a programme officer for a donor for the last 18 months. It calls for a focus on implementation of services within public health and education systems, the need to deepen the capacities of activists and build new leaders, and the value of alliances with other movements whose goals are also being challenged by macro-economic forces and fundamentalist movements. At national level, I suggest three major goals: monitoring public sector spending, strengthening public health system capacity for implementation, and advocacy and community organisation to enable shifts in public understanding of sexual and reproductive rights. Lastly, as regards funding, it calls for dialogue about funding issues between NGOs and donors, for donors to increase national capacity development in the global south and for all those committed to change in relation to sexual and reproductive health and rights to commit themselves for the long haul, given the slow pace of change.

Résumé

Cet article réfléchit à quelques-uns des succès et des obstacles rencontrés après la Conférence internationale sur la population et le développement (Le Caire, 1994), et à la capacité de la société civile et des donateurs d'y faire face. Il exprime deux points de vue–l'expérience de l'auteur comme activiste d'une ONG en faveur des droits génésiques depuis le début des années 80 et comme administrateur de programme pour un donateur ces 18 derniers mois. Il préconise de se centrer sur la mise en œuvre de services dans le cadre des systèmes de santé publique et d'éducation, de renforcer les capacités des militants et de former de nouveaux dirigeants, et de passer des alliances avec d'autres mouvements dont les objectifs sont aussi menacés par les forces macro-économiques et les mouvements fondamentalistes. Au niveau national, il suggère trois objectifs majeurs : surveiller les dépenses du secteur public, renforcer la capacité de mise en œuvre du système de santé publique, et mener des activités de plaidoyer et d'organisation communautaire pour réorienter la compréhension des droits génésiques dans l'opinion. Enfin, il souhaite un dialogue sur les questions de financement entre les ONG et les donateurs, et demande que les donateurs relèvent les capacités nationales dans le Sud et que tous les défenseurs des droits de santé génésique s'engagent à long terme, compte tenu de la lenteur du rythme de changement.

Resumen

En este artı́culo se reflexiona sobre algunos de los éxitos y retos como consecuencia de la Conferencia Internacional sobre la Población y el Desarrollo (CIPD), celebrada en El Cairo en 1994, y sobre la capacidad de la sociedad civil y de los donantes para asumirlos. Fue redactado en dos voces: una basada en mi experiencia como activista de una ONG a favor de los derechos sexuales y reproductivos desde principios de la década de los ochenta; la otra, en mi experiencia como funcionario programático para un donante durante los últimos 18 meses. Es un llamado a enfatizar la necesidad de implantar servicios dentro de los sistemas de salud pública y de enseñanza, ası́ como de aumentar la capacidad de los activistas y crear nuevos lı́deres, y para que se valoren las alianzas con otros movimientos cuyos objetivos también son retados por las fuerzas macro-económicas y los movimientos fundamentalistas. A nivel nacional, sugiero tres objetivos principales: monitorear los gastos del sector público, fortalecer la capacidad de implementación del sistema de salud pública, y organizar a los promotores de la causa y a la comunidad para permitir cambios en la comprensión pública de los derechos sexuales y reproductivos. Por último, en cuanto al financiamiento, se insta a las ONG y a los donantes a entablar un diálogo sobre los aspectos financieros, a los donantes a aumentar el desarrollo de la capacidad nacional en el hemisferio sur, y a todos aquéllos comprometidos a realizar cambios en relación con la salud y los derechos sexuales y reproductivos a hacerlo a largo plazo, dado el ritmo lento del cambio.

Key Words:

• International Conference on Population and Development
• donors
• non-governmental organisations
• advocacy and political process
• women's health and rights groups
• sexual and reproductive health policies and programmes

The International Conference on Population and Development (ICPD) in Cairo in 1994, followed by the Fourth World Conference on Women in Beijing in 1995, were watersheds for sexual and reproductive health and rights. The mix of progressive governments, feminists from NGOs on government delegations, and feminists caucusing in the corridors and offering delegations possible phrasings for the ICPD Programme of Action resulted in the first explicit UN consensus document that acknowledges that women's human rights extend to matters of sexuality and reproduction and that women, men and adolescents have the right to comprehensive information and services in this regard. Equally significant, the Programme of Action was the first that acknowledged that development was not only affected by population dynamics, but also by “unsustainable production and consumption patterns”. For the first time developed countries were being called to account for using up the world's resources rather than all the blame being put on individual women's fertility rates, which by and large reflected inequities in resource allocation, their poor levels of education and their poverty.

This paper is a reflection on the successess and challenges that followed in the aftermath of the ICPD, and the capacity of civil society and of donors to address them. It is written with two voices–from my experience as an NGO activist for sexual and reproductive rights since the early 1980s, my involvement in both national and international advocacy and training initiatives in the post-Cairo period, and my newer experience as a programme officer for a donor for the last 18 months.

In the ten years since ICPD, there have been many positive achievements, including the increased rights-based orientation in the service work of many NGOs; the increased involvement of service NGOs in advocacy for changes in policy and in public opinion; the channelling of funds to NGOs to elaborate methodologies and materials to support provision of integrated sexual and reproductive health and education services; the increased attention to violence against women, the buy-in of key foundations and international development NGOs to the ICPD agenda; and the commitment of UN agencies, particularly UNFPA and WHO, to reproductive rights, as evidenced most notably in WHO's technical and policy guidance on safe abortion. Some of the major challenges to implementation that remain include:

• the need to focus beyond policy changes, on implementation of services within public health and education systems,

• the need to deepen the capacities of activists and build new leaders within the women's health movement in order to be able to play this role,

• the need to widen the scope of the civil society movements so that those concerned with sexual and reproductive rights and health ally with other movements whose goals are similarly being challenged by both macro-economic forces and various fundamentalist movements, and

• the need to continuously engage donors about these and the broader ICPD agenda.

After ten years, the ICPD Programme of Action continues to be highly contested, however, rather than an approach which is moving towards becoming normative. This is not surprising, as policy achievements usually result in backlashes. The challenge to the ICPD “movement” is how to maintain momentum in this context. Two areas which have been particularly difficult to address are the distribution of resources and the recognition of groups such as women, homosexuals, lesbians and transgender people as fully human beings and citizens.

Distribution of resources

I would suggest that there are five key failures in relation to the distribution of resources to implement the ICPD Programme of Action beginning with the failure of governments to deliver on the funds committed in the ICPD Programme itself. The total commitments were US$17 billion by 2000 and US$18.5 billion by 2005. By the end of 2003, developing countries had met 92% of their agreed target, which was one third of the total, while developed countries had met only 50% of their agreed target, which was two thirds of the total.

Multilateral agencies and donors are moving away from the idea of financing governments to provide integrated public services–an explicit call of the ICPD. At the time, there was great interest in the sector-wide approach, in which donors would commit their funds to a pool to enable governments to have integrated strategies for delivering health and social services. In the last five years, we've seen some donors reverting back to funding vertical services to address specific problems, and the emergence of new donors promoting this approach. This trend is troubling because vertical approaches neither build public health and education systems nor address the needs of people as whole human beings who come to health services with diverse problems and get better attention if all their needs can be addressed together. This is manifest similarly in the articulation of the Millennium Development Goals, which identify maternal health and AIDS incidence as indicators, rather than provision of an essential package of public health services through a functioning health system which would address both, as well as offering a broader range of sexual and reproductive services.

Many bilateral agencies and private donors* have not fostered or funded NGOs and academic institutions in developing countries to initiate regional and international conceptual work, training and piloting of interventions. As a result, the construction of knowledge on sexual and reproductive rights and health remains open to accusations of western bias, and the capacities built over the last ten years have been disproportionately in the north.

There has been a slow decline in private donors' commitments to funding the sexual and reproductive rights dimensions of the ICPD agenda and the politically controversial dimensions (such as abortion and sexual rights), and similarly a decrease in their funding to advocacy NGOs, so that a wide range of once strong advocacy NGOs and networks are currently barely functional or have closed down.

There has been a shift in donor funding from “core” to “project” funding, requiring short-term deliverables, thus making it more difficult for NGOs to engage in long-term processes of social change and to make rapid strategic changes in their activities in response to changing political and social windows of opportunity.

The context for these difficulties has been the dominance of the Washington consensus, with the World Bank taking over from WHO as the arbiter of what constitutes good health interventions in the international health policy terrain, despite that its overarching intentions are economic rather than human welfare.

Fundamentalist critique of women's freedom and sexual diversity

The other challenge in this period is the increased strength of diverse fundamentalist movements, sometimes articulated in religious terms, sometimes not, which target women's freedom as the fulcrum of their critique of contemporary society. In the process they similarly deny, stigmatise and criminalise any expression of sexuality that is not overtly heterosexual. Whilst the impetus for such fundamentalism may be a sense of helplessness, particularly economic helplessness, the target for action of most movements is neither global economic institutions nor national governments' economic policies or corruption. Instead of addressing the institutions responsible for increased unemployment and global inequities, these movements have chosen to challenge women's freedom, and most particularly women's rights in relation to marriage, sexuality, fertility and inheritance. In many places the situation has never been good. But the last ten years have seen moves from mediocre to appalling for women in many parts of the world, across diverse religions. Some examples of how this manifests in different contexts include efforts to reintroduce female genital mutilation and in some countries to medicalise it, which, whilst ensuring more sanitary conditions, serves to legitimise the practice as a health service; efforts to remove comprehensive sexuality education from school curricula; and the ascension to positions of power of individuals with explicit religious mandates in a number of officially secular governments.

Strategies we should foster

To a large extent these problems are part of macro processes that had begun in the 1980s and result from a much wider set of geo-political and economic dynamics than one could ever expect a small women's health movement to overcome. However, there have been some successful strategies used to promote the ICPD agenda that can continue to be used in the context of current macro-challenges.*

Strategies for working on the inside

At WHO headquarters and regional offices, feminists–both men and women–have played a critical role in efforts to develop international guidelines as to what kinds of interventions are necessary to promote sexual and reproductive health, what constitutes feminist ethics in health research, and how to get health services to recognise and address violence against women. They have also enabled WHO to acknowledge the need for gender mainstreaming and to develop structures, policies and tools to support their own staff and that of government health departments in mainstreaming gender, both generically, and on specific issues such as tropical diseases, reproductive health and health information systems. But these advocates are few, and many sections of WHO remain disinterested or threatened by this agenda. Indeed, many of these interventions have required months and years of negotiation before being agreed upon.

Another significant strategy from within WHO has been to invite feminists from universities and NGOs from all parts of the world to work with them in collaboration with representatives of governments from different parts of the world. These experts from civil society have been engaged both in getting work done within WHO and in running their own initiatives in partnerships with WHO. Indeed, NGOs have started to engage WHO by inviting them to the table to enable greater dialogue between activists and academics on the one hand, and the UN system on the other.

A second example is the course developed by the World Bank Institute entitled Adapting to Change: Learning Program on Population, Reproductive Health and Health Sector Reform, which is a fine example of our strengths and weaknesses. In regions where there were highly skilled feminists willing to get involved, they have been able to make some impact on what was otherwise a course that was driven by the macro-economic concerns framing the Bank's health policies and that gave inadequate attention to issues of gender equity, sexual and reproductive rights, and social change. But as the organisers looked for health economists, epidemiologists and the like, feminists were seldom there. In order to engage the “establishment”, as it were, with the ICPD agenda, one is best served by having interdisciplinary experience. It is doubtless easier to be a doctor, economist or epidemiologist in that terrain, as one is perceived as having the expertise. Coming into this space as a sociologist, gender policy analyst or specialist in participatory teaching methods is difficult since these skills are devalued within the bio-medical paradigm, despite that it is these skills that are needed if one is to reshape the nature of health services. Hence the strongest advocates for change in this context are likely to be people who have crossed over medical and numerical paradigms with social and organisational paradigms. But they are not easy to find.

Monitoring ICPD implementation and pushing the international policy agenda

Significantly, progressive bureaucrats, in collaboration with national level activists and a handful of regional and international activists, have managed to prevent efforts by fundamentalists to undermine commitment to the ICPD at the various regional ICPD +10 meetings during 2003–04. But the international meeting in New York in 2004 could not reach a conclusion and had to sit again before finally completing a report. This reflects the changing political environment, but it also reflects weaknesses on the NGO side, at the international level, where there has not been the capacity for concerted work over time. One of the reasons for this is that there are still few institutionalised mechanisms through which these national and regional level activists can mobilise and sit at the table as equals at the international level. There are some new regional networks which represent and are mandated to speak for national level NGOs, but none representing Asian regions, the Middle East or North America. Moreover, there is no international mechanism through which these networks can identify their concerns in relation to international policy and collectively develop strategies. Only in the past year have they begun to meet to share experiences and consider strategic concerns.

As a result, to this day the general pattern is that international NGOs based in the US, Canada and Europe have handpicked individuals to conduct lobbying and advocacy activities at UN policy events. The recent Global Roundtable–Countdown 2015: Sexual and Reproductive Rights for All–is demonstrative of the north–south dynamic, with three northern NGOs making a major decision about how to relate to the tenth anniversary of the ICPD and only then inviting in other stakeholders. Yet until now, regional networks have not had the strengths or resources to consider establishing an internationally representative forum through which they could collectively strategise. More importantly, many of them are dependent on funding from international NGOs and hence are reluctant to challenge the status quo. What this means, is that the cadre of individuals and organisations mobilising for policy change at the international level and monitoring implementation remains extremely small and is barely regenerating itself. This is an untenable situation in terms of ensuring that the goals and strategies of international advocacy are based on a solid understanding of the lived reality of women in different countries, and on the ability of their organisations to speak for themselves and as representatives of constituencies.*

Aside from the very exciting development of some regional and international youth networks over the past ten years, there were few people monitoring the ICPD at the international level in 2004 who were not there in 1994. Whilst this continuity is important, a large new generation of activists is not being built by the “older” generation as a result of which much of the memory and strategic capacity of the movement is not being shared. In discussions on this issue with southern activists who have found themselves on the international policy circuit, two problems have emerged. The first is that because their participation is at the invitation of a northern NGO, and they have no organisational funds of their own for international travel, they cannot bring along someone new to train into this role, or replace themselves with someone else. This begs the question of why southern NGOs do not build international advocacy into their funding efforts, and why donors do not see the need for this. The second is an age-old problem of leadership, which is that it is hard to let go. Hence although some organisations working at both national and international levels make a point of giving opportunities to different members of staff to work internationally, others maintain this as the role of the director only, thereby failing to build up other cadres with international capacity. Some of the causes of these inequities are ideological–northern groups enjoying playing the role of interlocutor for the international women's health movement. But many are about resources, with northern groups battling to raise adequate funds to be more inclusive, and southern groups lacking the funds and capacity to demand their own inclusion or establish their own policy spaces. Another problem sometimes raised is language, since participants need to be relatively fluent in English to participate. Addressing this requires both vision and resources, as I witnessed recently with an Indonesian reproductive health NGO which includes English lessons for staff in its budget.

As long as things continue in this way, efforts at advocacy to take forward the international policy agenda will be somewhat ad hoc, such as the mobilisation of diverse groups in support of the Brazilian resolution on sexual orientation to the UN Commission. Were there a representative coalition of sexual and reproductive health networks, more systematic strategic work would be possible.

Another critical weakness in international advocacy is the lack of strategic alliances between sexual and reproductive health and rights networks and other networks which have some related interests, for example networks advocating for AIDS treatment access and rights of people living with AIDS, networks for interventions to address violence against women, and networks for rights of gay, lesbian, bisexual and transgender people. Were these diverse movements to recognise their shared interests, some of the underlying problems at the international level might be able to be addressed more coherently and with the support of wider constituencies. I would include in this not only linkage between those with linked interests mentioned already,which would be an achievement in itself; but also between those working to improve public education, public health and public welfare services, and those working for economic and environmental justice, so that the underlying sources of inequitable distribution of resources, and lack of recognition and denial of rights to marginalised people could be collectively challenged.

National strategies: working from outside to inside

As regards national level work, I will focus on three major goals that need sustained attention: monitoring public sector spending, strengthening public health system capacity for implementation, and advocacy and community organisation to enable shifts in public understanding of sexual and reproductive rights.

Given that most people will continue to rely on public health services, monitoring service delivery is one of the mechanisms available to civil society for holding governments accountable. One of the current activities in many countries is the establishment of mechanisms for community input into Poverty Reduction Strategy Papers (PRSPs) being developed by Heavily Indebted Poor Countries (HIPC) in anticipation of debt relief. In Uganda, the Uganda Debt Network (UDN) was formed by members of civil society, for example, and canvassed communities as to how they thought these funds should be used. They identified diverse sexual and reproductive health and rights issues, including youth concerns about inadequate HIV prevention strategies, and women's concerns about lack of adequate maternity facilities. They also found that health units were taking a long time to submit their “accountability statements” yet were receiving further funding before their statements were in, thus undermining the purpose of monitoring.¹ In response to these findings, the UDN embarked upon a process of establishing district monitoring committees. The role of these committees is to collect data, disseminate information to the public and work with government monitoring teams, sending the relevant information and other issues to the UDN to address at national level.²³

Whilst this is a critical step forward in civil society action to promote government accountability, it is not an area that many sexual and reproductive health and rights activists have engaged with. Given the interest in sexual and reproductive issues, this is the kind of process where sexual and reproductive health and rights NGOs might work with those from other sectors, to ensure that the ICPD agenda remains on the table and is given content through the allocation of funds for its implementation. If these NGOs do not concern themselves with where the resources will come from to deliver public services, nor whether they are spent responsibly, then their advocacy for sexual and reproductive health and rights is decontextualised. If they do not worry about the ongoing pressure to privatise services, and the introduction of fees for services, then who will? The entire infrastructure for service provision will continue to collapse, rendering advocacy for sexual and reproductive health and rights meaningless.⁴

Much of what has had to be done post-ICPD is about implementation. Many health services are not based on detailed policies. In other cases there are policies, and what is required is to interpret them in a progressive manner. In both cases, what is needed are progressive managers–bureaucrats–in departments of health at all levels and progressive health workers. Brazil is a case in point, described in several papers in RHM, in that activist members of the Brazilian women's health movement are also doctors and public health specialists working in the government, who could therefore push the envelope, despite the strength of Catholic fundamentalism in Brazil. For example, the modelling of the establishment of high quality abortion services for women who had been raped in one municipality run by a feminist from the women's movement–allowing legal abortions to be carried out in Brazil–enabled others to follow suit.⁵ In this way the demands of ordinary women could be incorporated into public health service provision. At the same time, advocacy NGOs continued to work with diverse stakeholders to extend the provisions of the law.

One of the immediate spin-offs of Cairo was the lesson that strategies for change need to suit the context. During the ICPD, CNN showed a video of a girl going through female genital mutilation (FGM) in Egypt. This led to international calls for the banning of the practice, with both positive and negative reactions within Egypt. In particular, it increased the interest of certain groups in promoting the use of health workers for this procedure, on the basis that it could then be done more humanely (e.g. with pain relief) and more safely (with sterilised instruments). From the perspective of most Egyptian feminists, this call further legitimised FGM by suggesting that it was a medical procedure, and did not help in the struggle to eradicate it. Instead, many activist groups have engaged in long-term work within communities to build awareness among those in leadership and those benefiting from FGM, as well as that of women and men who cannot imagine a different world.⁶⁷⁸⁹ It has taken a long while to figure out what appears to be working and what does not in these efforts. Five years after ICPD, most commentary on projects addressing FGM was descriptive, with claims of impact but no way of drawing out lessons to share or of knowing whether immediate impacts would hold over time. Only now are we starting to see deeply reflective methodologies being implemented, with measurable indicators against which to monitor progress over time (Toubia N, Rainbo. Presentation to the Ford Foundation, 2004).

To some extent this is an inevitable process–it takes time to build know-how in advocacy groups to address specific issues, and it takes longer to work out what to do. But one of the noticeable problems in this process is the idea that one can develop and duplicate a given set of steps, irrespective of context and partners. Instead, what is needed are the resources to support local activism, whilst enabling activists to share their experiences with others. In addition, the support of academics is needed to research the phenomenon, in this example to examine claims that FGM is part of a people's tradition, culture or religion, which is genuinely felt by many people but is also emerging as part of new religious fundamentalisms. Different claims are made in different contexts, but activists would be well supported by access to good quality historical and contemporary research. Yet there is little motivation for academics to work on sexual and reproductive rights issues, since few disciplines reward research on taboo issues, and academics are inevitably driven by concerns for tenure.

Who will fund this work?

All these matters beg the question of funding. In the best of all possible worlds, governments would fund public health services, sexuality education, shelters for battered women and other essential requirements of citizenship. In the real world they seldom do so adequately, if at all, so NGOs frequently fill this gap. To get governments to take on these responsibilities, it is essential for international multilateral technical support organisations, such as WHO, and civil society organisations, universities and NGOs to challenge the Washington consensus and get involved in building capacity for government service provision. They can play critical roles in providing the motivation and skills–both for service provision and management–required to address both sexual and reproductive health and rights and other public health services. Furthermore, they need to monitor implementation, both to support bureaucracies in doing better and if necessary to embarrass them through the media and other publicity for not doing better. This requires money and takes us back to the issue of access to resources.

In addition to the problem of lack of funds for governments to address sexual and reproductive health and rights, there is the problem of shifts in donor interest in the field and donor willingness to provide “core” support to advocacy organisations. Implementing sexual and reproductive health and rights programmes takes time as it is premised on the need for changing deeply embedded social values. What does this mean in a context in which NGOs conducting this work are expected to show an impact within the first year of funding? Indeed, they can frequently only fundraise for a year at a time and often for very specific projects.

Equally importantly, work to change social values needs community members to be involved, not on and off, but in shaping and managing the process. Yet few donors are able to fund small initiatives with very low costs. Donors would rather fund an intermediary to support such projects, and while this sometimes works, it frequently limits the power and depth of participation of local groups. More importantly, it is the intermediary who then gains the skills at engaging in advocacy, fundraising and financial management, all of which are essential for capacity development, while community-level organisations remain dependent. The issue of how to address donor need for intermediaries given the shared concern to build local capacity needs further exploration.

An enabling environment for fundraising

The legal frameworks that provide an enabling environment for private donors and for international NGOs, which effectively function as donors, differ from country to country. Yet NGOs seldom think about these issues as matters of concern to them, even though they may well need to be raising questions about an enabling environment for funding as part of their agenda. For example, I was struck, on arriving in the US to find that any taxpayer can deduct from their pre-tax income money that they have contributed towards charitable activities, which could include most of the NGOs in the sexual and reproductive health and rights movement. A whole new range of fundraising opportunities might arise–albeit requiring new skills and substantial time-in which those with money might be persuaded to contribute not purely out of goodwill but because in doing so they would gain a tax benefit. This is the kind of issue that NGOs, irrespective of their area of interest, might collectively work on in relation to national policies on corporate and individual charitable donations.

Another issue which needs to be considered by NGOs is that donors are also working in a political context, and the same issues that are politically risky for NGOs can be risky for donors too, especially if government policy is unsupportive. Similarly programme officers employed by a donor can make themselves vulnerable within the institution by taking on a risky issue. Donors too have constraints–legal requirements depending on where they're located; interests of those who give them money, whether governments or private individuals; and shifts in the stock exchange so that the amounts of money they have at their disposal can fluctuate over time. Donors are and should be accountable for how they spend their funds, which are by and large public funds, funds that came from national funds or would have gone to the taxman had they not gone to the donor. But they are not accountable to the movement which they fund, but rather to their board of governors or trustees or whoever runs them. As with all institutions, donors have tensions between and within their institutions, and understanding these might help NGOs to identify entry points for attracting resources.

Challenges to current donor strategies

There are two issues I can discern which need to be re-thought by the donor world. The first relates to increasing national capacity development in the global south; the second relates to indicators for measuring impact. In both cases, these are of keen concern to most donors, and potential entry points for donor–NGO engagement.

The meaning of “technical support” for building national capacity

One of the cornerstones of bilateral and multilateral funding aid is “technical support”. The notion that technical support is neutral is fallacious. All technical support is values-based and comes with notions as to what good service is, what the role of government vs. the private sector is, and to what extent the public sector should challenge existing cultural relations, such as the subordination of women. Much of the donor money that goes to technical support goes to NGOs, universities and individuals in the donors' countries. All my experience is that when technical support teams are not comprised of people trained in the country they are supporting, and with working experience in that country, the solutions they offer will be less realistic and responsive to the actual environment. More importantly, technical advisors bring with them the ideology of the donor country. Sometimes this is very progressive, sometimes not. The last decade has seen the development of literally hundreds of models for programme implementation that have been developed by experts in one place and dropped onto communities, cities and even provinces in other parts of the world, irrespective of the context or their capacity. As an NGO colleague said to me last week: “I keep training wonderful and enthusiastic young people in NGOs, but they're implementing programmes imported into the country when they themselves know nothing of the impact of population policies, the nature of the public services or the demands of the people.”

There is a grave danger that long-term institutional strengthening to build local capacity in the global south is not getting adequate investment. What the global south needs in the sexual and reproductive health and rights field is inclusion of these issues in curricula in medicine and nursing, public health, law curricula and journalism. It needs MBAs and MPHs who train people in how to manage public services effectively. It needs across the board training in policy analysis and the relationship between policy and implementation. In the long run, these skills would enable governments to run services effectively, so that donors would not have to shore-up government capacity indefinitely. Similarly, these skills would enable young activists to strengthen indigenous NGOs that talk to local experience but can engage with confidence at the international level too.

These problems raise questions about the norms of donor support, and donors need to be challenged to support the indigenous development of civil society and the strengthening of higher education in countries of the south. In the absence of these, global inequities will continue to be fostered.

Making indicators meaningful given the pace of social change

As regards the issue of indicators, it might be easier to win donor support for the sexual and reproductive health and rights field as a whole if NGOs, donors and other recipients of funding could find common ground on indicators. It is obvious why it is easier for a donor to see and feel good about something measurable–number of condoms distributed or number of people receiving antiretroviral treatment, for example. Whilst donors no doubt feel deep concern about high levels of violence against women or the vulnerability of young women to HIV, they also need to be able to monitor impact¹⁰ and make concrete claims about progress in order to persuade their boards that they are spending their money effectively. Of course, people doing the work also want to know whether it is achieving the intended objectives.

But the trend of shifting from core to project funding is not necessarily the best solution. It assumes that major social change processes can be planned and achievements measured year by year, and that there will be no need to change strategies in response to a changing environment. In addition, it makes long-term planning and leadership and institutional development almost impossible for NGOs. Finally, if NGOs have to shape their interventions as “products”, they are unlikely to develop the sorts of innovative strategies needed to influence policy change, and if they have only project funding, they may be unable to respond to unexpected windows of opportunity.

Since change is slow, particularly in a contested field like sexuality and reproduction, it may not be visible using the usual indicators, i.e. changes in policy or public attitudes, or implementation of a new service. Major social changes take time and organisation, and require many factors to be at play at the same time–whether elections or the support of a particular Minister of Health, or strong public demand. Policy is not changed in a day. Public opinion is not changed in a year or even five years. And policy implementation usually takes years before it can be fully effective across a whole country. Policies are always influenced by those responsible for implementing them, and hence, as discussed earlier, monitoring and supporting the implementation process itself is essential.

This may all seem self-evident, but it does not fit well with the current obsession with rapid results. It means that those committed to change have to be there for the long haul; they cannot support sexual and reproductive health and rights like a fashion–this year FGM, next year antiretrovirals. These issues are complex and hard and need commitment. This raises critical questions for NGOs, as to how they set themselves up, and what expectations they set for themselves and others they work with. How do they maintain commitment when there are so many barriers along the way, when every two steps forward seem to be followed by one or two steps back? And, more specifically, what sorts of indicators does one use to monitor progress over time given this reality? This calls for indicators of processes towards change and of small achievements such as a shift in news coverage; maintenance of community participation levels over time; reorganisation of services in one clinic at a time; or inclusion of training on medical abortion in one medical school curriculum at a time.

It is important to be able to notice and celebrate small changes, based on a realistic theory of change, and to monitor such changes, not just to bolster the organisation's commitment but in order to maintain the sexual and reproductive health and rights movement as a whole over time.

How might NGOs further engage the donor world?

Having shifted myself from working in an advocacy NGO to being a donor, I am struck by the ad hoc nature of civil society engagement with donors and more importantly, by the fact that by and large it is the donors who initiate such engagement. At my foundation, funding for most new initiatives begins with widespread consultation with diverse stakeholders about the issues, and often includes one or many “convenings” to air the options and gain insights into the concerns of stakeholders. But although many individuals whom I knew in my pre-donor life have asked me why it is that certain donors are not funding what they used to fund, or why they have changed their style of funding, to my knowledge there has been no initiative from civil society to make donors aware of these concerns beyond individual comments, usually to programme officers, who are seldom the decision-makers regarding what level of funding is available or the parameters of its disbursal by their own institution. My response is increasingly to ask “why don't you invite them to a meeting to talk about it?”. NGOs pride themselves on their ability to innovate and influence policy. Where are they in trying to influence donor policies? Where are they in trying to help donors understand current challenges? So I find myself throwing the challenge back.

In the US, donors have “affinity groups” where they meet across shared interests; these would offer an easy mechanism for a group of NGOs to engage donors. Similarly, given that many NGOs in the global south are funded by international NGOs, the regular meeting of EURONGOS might provide an appropriate platform for them to engage with Europe-based international NGOs that are funded by both European governments and US foundations. Of course, this goes back to my earlier point about the need for national groups to organise regionally and regional groups to organise internationally, in order to have a clear and mandated strategic voice for such discussions.

Since joining the donor world I've realised that being in the donor community means losing touch with emerging issues on the ground (whether country-level, regional or international) unless kept up to date. The work itself does not always permit adequate time to read or participate in meetings to keep abreast. Hence grantees can play a critical role in keeping donors in the loop through reports, phone calls, press releases or e-mail notes, with this end in mind.

Another insight I would like to share, now that I'm on the “other side” is that when I was in an NGO, what I wanted from a donor was to receive the funds and to be left alone. Now, as I sit in New York, it's clear to me that those grantees who engage me, including about their difficulties, and who keep me abreast of their progress and challenges are the ones I can understand best. And those I can understand best are those who are most likely to be able to challenge me about my understanding and my choices. NGOs cannot and should not take their direction from donors. But they do need to account to donors for the funds they receive, and the more intelligently and honestly they do this, the better a donor is able to advocate for them. In short, the greater the communication and the more honest it is, the better the overall funding environment is likely to be.

In conclusion, I would suggest that the time is ripe for NGOs to engage donors-both government and private-given the mutual concern of many donors and NGOs for addressing the enormous challenges in sustaining and implementing the ICPD agenda.

Note

This paper is written in my personal capacity.

Notes

* By private donors, I mean predominantly US and European foundations.

* By definition many of the strategies I will explore are those one might characterise as working on the inside of the establishment, since this is the work that is needed if one is to change the establishment bit by bit. These are not strategies of opposition and protest, many of which have also been necessary and successful during this period, e.g. the public mobilisations for access to antiretroviral treatment for people with AIDS. It is my assumption that there is always value in people working from both inside and outside to change public opinion and create greater options for social change. The ICPD Programme of Action is a UN consensus agreement, however, and is about government commitments; it thus provides a platform for working on the inside and engaging governments.

* It would require a different paper to reflect on the problem and impact of many NGOs not having forms of accountability to the people they service or on whose account they advocate; or not having staff from these groupings.