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The USG International Family Planning Mural: Defining Approaches to Address Uncertainties in Funding and Programming

Discussion Summary

May four, 2018

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This document represents a summary of discussions from a family planning leadership retreat co-convened past the Center for Global Development and the Kaiser Family Foundation on Jan 18-nineteen, 2018, in Washington, DC. While information technology reflects the principal ideas of the retreat participants, it is not a consensus document and is non intended to represent the views of whatever individual or organization. This document was prepared past Felice Apter, Amanda Glassman, and Janeen Madan Keller (Center for Global Development) and Jen Kates, Kellie Moss, and Adam Wexler (Kaiser Family Foundation). Jessie Lu assisted with overall evolution and production. The authors are grateful for contributions from the Pecker & Melinda Gates Foundation in back up of this work.

Summary

Background

The international family planning community has made impressive gains in increasing global access to high-quality, voluntary family planning services. As of July 2017, 309 meg women and girls in 69 FP2020 countries were using a mod method of contraception, representing an increase of 38.viii one thousand thousand users since 2012.^[1] Even so, meaning challenges remain with maintaining current support and coming together the growing need projected for family unit planning services and commodities beyond low- and heart-income countries (LMICs). A key challenge is the doubtfulness surrounding future funding for such efforts from international donors in detail, but also from host state budgets. These concerns are further exacerbated by the political mural in the United States—the largest single donor to global family unit planning efforts—including proposals to significantly cut the U.s.a. international family planning budget also equally other policy changes. Given the electric current climate, a forrard-looking agenda to address the potential implications of increasing unpredictability in future funding too as policy shifts for family planning programs is more important than ever.

Purpose of Retreat

Through their corresponding analytic work tracking funding and policy trends in family planning and linking those changes to larger global health and development paradigms, the Center for Global Evolution (CGD) and Kaiser Family unit Foundation (KFF) identified a need to hash out the implications of doubt in the global family planning mural for policy, programs, and people. To this end, CGD and KFF convened a family planning leadership retreat on Jan 18-19, 2018, that brought together a range of stakeholders from the international family planning space, also as the broader global wellness and development community. Participants included US authorities officials, other donors and international organizations, NGOs, and the private sector.

The meeting was designed to identify practical strategies and approaches going forrard. Three interconnected focus areas were identified as loftier priority:

1. Financing and Policy Changes: Dubiousness of future donor back up and financing implications of policy changes;
2. Country Transitions: Acceleration of country transition timelines and realistic assessment of domestic resource mobilization opportunities; and
3. Commodities: Possible decreases in support for commodities and country supply chains.

The retreat included overview presentations in each of these three focus areas followed by related break-out sessions to more specifically identify strategies for farther consideration.

Retreat Outcomes

The retreat'due south discussions yielded several cantankerous-cutting themes across the three focus areas: ane) improve donor alignment; 2) mensurate and mobilize domestic resources; 3) fill data gaps; 4) support integration while maintaining a focus on family unit planning; and 5) recognize that incertitude also provides opportunity. These are discussed in more depth beneath. In add-on, physical ideas for potential approaches and strategies in each of the three focus areas are provided in Table one and in individual discussion overviews.

1. IMPROVE DONOR ALIGNMENT: The need for enhanced donor alignment of family planning investments is not new, but it has taken on increased urgency in the current environs.^[2] In particular, participants identified improved alignment effectually country selection and prioritization for funding, with a focus on which countries or sub-regions might exist most vulnerable to short-term funding reductions, as an urgent need. Coordination effectually longer-term planning equally countries transition from aid eligibility is also needed. Participants also discussed the need to examine and reduce donor inefficiencies at the country and global levels (e.g., addressing parallel supply bondage). Curt-term strategies can exist designed with the goal of serving as a bridge to longer-term strategies for sustainable funding and program self-sustainability.
2. MEASURE AND MOBILIZE DOMESTIC RESOURCES: Participants identified a disquisitional need to better empathise the landscape of domestic resources for family planning, including current spending levels by national governments, fiscal space for additional spending, and political will. Such assessments should be pragmatic and will need to consider the difficulties in tracking family unit planning-specific expenditures inside national budgets and challenges around accounting transparency more generally. Information technology is also of import to be cognizant of the fact that countries may be experiencing multiple aid transitions in areas across family planning, as well as other overarching development challenges, magnifying budget pressures. Furthermore, considerations of fiscal space for family planning should recognize that national governments have competing priorities both within and outside the health sector. Agreement each country's fiscal infinite and political will tin can help donors program resources most finer. In addition, building capacity in such areas every bit contracting, developing insurance schemes, and fiscal tracking will exist an important component of efforts to ensure greater regime self-sufficiency.
3. Fill Data GAPS: Participants identified several areas where critical data gaps limit the ability of policymakers, implementers, and other stakeholders to plan effectively. These include the lack of information on:
   • Relative effectiveness of key investments
   • Overall projected cost to encounter family planning need beyond both the public and private sectors
   • Improved understanding of family unit planning service costs
   • Current domestic expenditures for family unit planning^[3]
   • Measures of fiscal space

   Working to fill these data gaps volition be of import for informing planning and decision-making going frontwards.

4. Back up INTEGRATION WHILE MAINTAINING A FOCUS ON FAMILY PLANNING: The importance of integrating family planning with other global health and development programs, where possible, was highlighted. Indeed, for the by several years, PEPFAR has sought to increase integration of family planning and HIV programs, and currently, USAID is seeking greater integration across global health programs. At the same time, participants discussed the need to ensure that family planning efforts do not get diluted or minimized through integration, peculiarly given the often-politicized nature of debates about US family planning efforts.
5. RECOGNIZE THAT UNCERTAINTY Too PROVIDES OPPORTUNITY: Although discussions focused largely on the challenges that accompany donor uncertainty, participants identified several important opportunities. In that location was emphasis on transition as an opportunity to ameliorate understand countries' progress and needs and to strengthen implementation of, and accomplish efficiencies in, international family planning assistance. Moreover, increased downward force per unit area on budgets also presents an opportunity to improve harmonize investments across donors and aqueduct available resources to areas of greatest need.

TABLE ane: KEY IDEAS AND PROPOSALS By FOCUS AREA

I. Financing and Policy Changes
Vulnerability Assessment: Support a more systematic assessment of country vulnerabilities to changes in external financing, including identifying factors/ indicators that could be used to help predict vulnerability. Country Prioritization: Re-examine the methodology used for prioritizing USAID family unit planning countries to prepare the stage for enhanced donor coordination. Stakeholder Involvement: Identify ways in which the larger family planning customs tin support a USG country prioritization process and vulnerability assessment in the context of funding uncertainty. Contingency Planning: With the reinstatement and expansion of the United mexican states City Policy (MCP), renamed Protecting Life in Global Health Aid (PLGHA), the USG and/or other stakeholders could develop a process to place where gaps in family planning access are nigh probable to occur and, where gaps exist, identify other sources of funding and/or alternate implementers. Donor Coordination: The main family planning financing actors could more proactively engage in assessing and responding to family planning aid vulnerabilities and prioritizing allocations using existing fora. Domestic Resources Tracking: Enhance efforts to track domestic resources for family planning, including assessments of fiscal space and political will needed to support increased domestic investment. Innovative Financing: Utilize innovative financing instruments, where appropriate, to incentivize sustainability.
2. Country Transitions
Transparency: Enhance transparency as a strategy to reduce doubtfulness and increase the likelihood of success. Transition Criteria: Revisit criteria to be used at different points along the transition continuum for family unit planning programs. Domestic Resources: Increment domestic spending on family unit planning, particularly in lower-center-income countries and/or pinnacle transition candidates. Total Market Arroyo: Take a "total market approach" to transition. Lessons Learned: To reinforce and build upon lessons from previous experiences, set up a project, initiative, or clearinghouse on transition (or build this into FP2020). Broader Transition Strategies: Reconsider and strengthen broader approaches and strategies to transition.
Iii. Commodities
FP-Specific Challenges: While challenges around procurement and distribution of family planning bolt are relevant to other global wellness areas more broadly, some complexities are unique to family planning. Resource Allocation Collaboration: Raise collaboration effectually strategic resource allocation for family planning commodities, over the short-, medium-, and long-term. Country-level Planning: Place opportunities for global actors to further harmonize structures and planning at the state level for family planning commodities—and explore opportunities for synergies with other wellness commodities. Assess Existing Landscape: Support assessments to better understand the overall commodities landscape and identify potential gaps and possible efficiencies. Procurement Coordination: Heighten procurement coordination across public and individual sectors to further improve pricing and ensure contraceptive supply security as need grows. Global Planning Pinnacle: Explore the possibility of a "global planning superlative" on family unit planning commodities.

Focus Expanse Discussion Overviews

I. Financing and Policy Changes

Problem Argument and Background

Donor government funding for family planning is on the decline and future funding from the single largest donor—the United States—is uncertain. In improver, a number of recent US policy decisions regarding family unit planning contribute to this doubt.

Figure I-A

Recent analysis finds that donor government funding for family planning is on the pass up, even later accounting for currency fluctuations and other factors (see Effigy I-A).^[iv] Moreover, future funding is uncertain in large part due to the current fiscal and policy environment in the United States, the single largest government donor to family planning (providing 45 percent of bilateral funding in 2016). The Trump administration has proposed deep budget cuts to global family planning, including zeroing out the global family unit planning program budget in the President's FY 2018 budget asking. Congress has indicated that it volition not back up cuts of this magnitude, as evidenced by the FY 2018 Omnibus that included $607.5 million for family planning/reproductive health, matching the FY 2017 enacted level.^[5] Notwithstanding, the administration's proposals to significantly reduce global family planning funding proceed.^[6] Furthermore, the larger backdrop of Usa budgetary challenges is putting downwardly pressure on discretionary spending across the board. Considering the U.s. is the largest regime donor to family planning, partner countries are particularly vulnerable to any potential US cuts. This is fifty-fifty more than pronounced in the 24 USAID family unit planning priority countries,^[7] where the U.s. provides an estimated 76 percent of donor support overall, including more than xc percent in eight of these countries (run into Figure I-B).^[8]

In addition, a number of contempo U.s. policy decisions regarding family unit planning farther contribute to dubiety. These include the administration's withholding of funding to the Un Population Fund (UNFPA) under the Kemp-Kasten Subpoena^[ix] and the reinstatement and expansion of the United mexican states Metropolis Policy (MCP), renamed Protecting Life in Global Health Help (PLGHA)^[10] by the current administration. On the latter, there remain many unanswered questions about the policy's touch on, simply early analyses indicate that the expanded policy could apply to more than $7 billion in global health funding and, by conservative estimates, more than 1,000 foreign NGOs, likely leading to service coverage gaps in some geographic areas and for some populations.^[11]

Effigy I-B

Key Ideas and Proposals

Overarching Discussion Goal: Given dubiousness surrounding future family planning funding, it will be important for the main financing actors to engage in a more structured, transparent, and harmonized contingency planning process to help drive a rational prioritization of resources.

Participants identified means to address and potentially mitigate financial and policy incertitude, including:

1. Back up A More SYSTEMATIC ASSESSMENT OF Land VULNERABILITIES TO CHANGES IN EXTERNAL FINANCING, INCLUDING IDENTIFYING FACTORS/INDICATORS THAT COULD BE USED TO Assistance PREDICT VULNERABILITY.
   • Participants discussed the demand for articulate and consistent metrics to assess the vulnerability of countries to changes in financing, including identifying metrics for measuring vulnerability.
     • Amidst the factors discussed were country income classification; other financial resources available (external and domestic sources); social insurance; and vulnerability of populations (including adolescents, women, and girls in humanitarian contexts).
   • Donors take varying approaches to country prioritization, using different criteria and processes. A review of their respective prioritization methodologies could allow donors, including USAID, and other stakeholders to proactively identify countries with the most need of external assistance and to scale funding flows accordingly.
   • There was discussion on how funding uncertainty afflicted USAID country mission decisions, which, in turn, could brand some countries more vulnerable to changes. Specifically, information technology was noted that, faced with dubiety, some missions may choose non to include family planning in their future state strategy and budget requests, which could affect actual services in the field.
   • Lastly, participants felt it was important to non just focus on country and implementer vulnerability; rather, it was too important to understand and document factors supporting resilience. Identification and documentation of lessons learned from countries, implementers, platforms, etc., that accept demonstrated resilience to fiscal and policy changes and uncertainties could provide insight to future decision-making.
2. RE-EXAMINE THE METHODOLOGY USED FOR PRIORITIZING USAID Family PLANNING COUNTRIES TO Gear up THE Stage FOR ENHANCED DONOR COORDINATION.
   • Participants discussed how best to prioritize Us family planning priority countries/investments, the challenges to doing so, and opportunities for doing information technology better.
   • While USAID supports family unit planning programs in approximately 40 countries, it focuses its effort in 24 high-priority countries and the Ouagadougou Partnership countries. Such prioritization tin can serve many purposes, including helping to focus limited resources where need is greatest; assisting with contingency planning given funding uncertainty; and allowing for more proactive transition planning as the United States Government (USG) seeks to decrease its investments and in turn increment host country government spending over time. In the example of USAID's family unit planning program, these 24 countries too align with U.s.a. maternal and kid health (MCH) investments (23 of the 24 countries are also USAID MCH priority countries).
   • At the same fourth dimension, the list of priority countries has been static for many years,^[12] raising questions about whether there are better ways to prioritize countries to accost emerging gaps or other challenges (east.g., the use of S-curves depicting the growth trajectory of modernistic contraceptive prevalence^[xiii]).
   • In add-on to prioritizing countries, participants discussed the need to better assess prioritization of service delivery within countries across both public and private sectors. Such efforts could be significantly aided with ameliorate data on service effectiveness. Fundamental questions to enquire might include: What is the most impactful set of services to support in a particular land? How could greater efficiencies exist achieved? Are in that location interventions that should no longer be invested in? Can interventions exist better matched programmatically and geographically to their positions on the modern contraceptive prevalence charge per unit S-curve?  Participants also asked what lessons could exist learned from PEPFAR, which has undertaken such an exercise across their activities and redirected investments to more effective services.
   • Another outcome raised was the need to map the range of donor family planning investments and country prioritization approaches. This not but could help to "right size" investments or redirect investments to where they are needed most, only also help to assess land vulnerabilities to funding shifts. For instance, donors might find instructive analyses of data like that in Effigy I-B, which shows U.s. family planning investments as a share of all donor investments in the 24 USAID family planning priority countries. Such analyses could exist expanded to include all FP2020 countries.^[14]
   • Finally, it will be important for any family planning prioritization effort to be connected to USAID's larger, bureau-wide effort to harmonize land prioritization beyond programs and to identify factors that support country self-sufficiency.^[15]
3. IDENTIFY WAYS IN WHICH THE LARGER Family PLANNING Customs Can Back up A USG COUNTRY PRIORITIZATION PROCESS AND VULNERABILITY Cess IN THE CONTEXT OF FUNDING UNCERTAINTY.
   • Participants identified several key areas where the larger customs could support this process, including:
     • Proactively identifying the changes that could occur;
     • Convening leadership across donors to develop a plan to minimize disruption of family planning bolt and services in both public and private sectors;
     • Identifying the capacity of other stakeholders to step in, including prioritizing support to whatsoever gaps created by the loss of U.s. technical leadership; and
     • Developing a strategy to measure and track the impact of "shocks" (due east.g., funding reductions, abrupt transitions, policy changes) in 1) outcomes, ii) processes, 3) shifts in implementers and providers (including costs associated with these changes), and iv) lessons.
4. WITH THE REINSTATEMENT AND EXPANSION OF MCP/PLGHA, THE USG AND/OR OTHER STAKEHOLDERS COULD DEVELOP A Procedure TO Place WHERE GAPS IN FAMILY PLANNING Admission ARE Nigh LIKELY TO OCCUR AND, WHERE GAPS Be, Place OTHER SOURCES OF FUNDING AND/OR ALTERNATE IMPLEMENTERS.
   • Participants stated that short-term efforts are needed to identify anticipated gaps and alternate sources of funding and implementers.
   • Participants discussed the many kinds of bear upon assessments that are needed to build on the USG efforts (some of which are underway) including:
     • short-term, more than "real-time" assessments to place needs and gaps; and
     • longer-term research (since the time between congressional appropriation and USAID programming means that effects of decreased funding and policy change may non be felt for several years).
   • The types of impacts to predict and assess include immediate service gaps, adverse wellness outcomes, effects on sustainability, and the additional costs of having to respond to the policy and/or seek new implementers.
   • Equally gaps or needs are identified, the community coordination endeavor should include more contempo initiatives and newly engaged donors—SheDecides is one possible mechanism.^[sixteen]
5. THE MAIN FAMILY PLANNING FINANCING ACTORS (BILATERAL DONORS, GLOBAL FINANCING FACILITY, UNFPA, WORLD Bank, PRIVATE DONORS, THE Private SECTOR) COULD More than PROACTIVELY ENGAGE IN ASSESSING AND RESPONDING TO FAMILY PLANNING Help VULNERABILITIES AND PRIORITIZING ALLOCATIONS USING EXISTING FORA.
   • It was noted that existing venues that join the main family planning stakeholders could exist utilized more proactively and purposefully to discuss prioritization and planning for such alter or "shocks" (e.g., funding reductions, precipitous transitions, policy changes). Specifically, participants identified the FP2020 Initiative as a potential vehicle for such efforts, including its Reference Group and State Technical Teams.^[17]
   • These existing mechanisms are well poised to facilitate such discussions, which could be expanded to include other stakeholders (e.yard., SheDecides) that may have resources to contribute.
6. ENHANCE EFFORTS TO TRACK DOMESTIC Resource FOR Family unit PLANNING, INCLUDING ASSESSMENTS OF FISCAL SPACE AND POLITICAL Will NEEDED TO Back up INCREASED DOMESTIC INVESTMENT.
   • While in that location is a global judge of the share of family planning expenditures provided by domestic governments (29 percentage), data on domestic expenditures is significantly limited at this time.^[eighteen] This was identified by participants as a critical data need. While there is piece of work underway to appraise what is currently being spent, it is limited to a subset of countries and will accept some fourth dimension.^[19]
   • Key points raised included the following:
     • It will be important to work with national governments to help with resources tracking efforts, including through technical assist. In some cases, systems may non be in identify to hands runway expenditures by programme area; family unit planning may non be programmed equally a separate line detail; and/or some countries are decentralizing wellness programming and funding.
     • Experience suggests there is fiscal space for governments to increase their investments in family planning, just political will is also needed if such investments are to be secured; assessing political will, therefore, also exist critical.^[20]
   • The Us and other donors tin work with countries to raise the incentives to increase resources from their governments and to back up/maintain the political will to do then; in some cases, this may also include the need to address increasingly decentralized decision-making.
   • To the extent that the United states and other donors decide to transition out of countries, information technology volition exist important to provide technical assistance to support successful transitions, fifty-fifty when domestic resources are bachelor.
     • Areas identified include supporting countries and local NGOs in developing ways to strengthen contracting mechanisms, including addressing payment delays from governments to NGOs; regarding the latter, some suggested that the USG or other donors could serve as a guarantor of authorities payments to support implementers of service commitment.
7. UTILIZE INNOVATIVE FINANCING INSTRUMENTS, WHERE Advisable, TO INCENTIVIZE SUSTAINABILITY.
   • Discussions covered several possible approaches (note: while these approaches could relate to family unit planning programs more broadly, they could also take a more specific focus on commodities, for example).
     • Interest-free loans (east.g., DfID – l years, no interest);
     • Bridge funding mechanisms (e.g., UNICEF Vaccine Independence Initiative^[21]), revolving funds (due east.chiliad., PAHO Revolving Fund^[22]);
     • Joint trust funds to secure longer-term investments (eastward.g., International Finance Facility for Immunization^[23]);
     • Debt relief / debt purchase-downs (either for family planning lonely and/or the larger wellness portfolio as long equally bolt are included); and
     • Banks or donors serving equally guarantors (note: there was some concern about fees charged past for-profit entities).

II. Country Transitions

Problem Statement and Background

Family planning gains may be at chance due to possible abrupt and/or accelerated country transitions by donors, including the US. At the same time, at that place is an opportunity to advisedly plan and execute strategic transitions in close partnership with countries, which could in plough assist to alleviate pressure on tight donor budgets.

Many donors, including USAID, are considering policies to reduce assistance allocations to countries and strategically transition select countries away from traditional grant-based assistance. Centre-income countries, in detail, are idea to have increasing fiscal infinite for public spending and could have on all, or most, of what donor assistance is currently funding, if in that location is sufficient political will. However, assessing the ability of countries to exercise so and successfully managing such transitions are challenging.

Commencement, country-level estimates of domestic government spending on family planning, which are critical to appraise readiness for transitions too as to ensure that family planning investments keep, are hard to define.^[24] While at that place are indications that domestic government spending on family unit planning is growing in a few middle-income countries—signaling that family planning is a domestic priority in some countries—the amounts are non significant in relation to anticipated needs.^[25] According to initial estimates from the UNFPA-NIDI Resource Flows Projection, for 69 FP2020 countries—comprising low-income countries and some lower-middle-income countries—national regime spending accounts for about xxx percent of family unit planning expenditures, international donors contribute 50 percent, and consumers' out of pocket spending makes up the remaining 20 percentage.^[26] Moreover, domestic spending priorities are also affected past health sector and budget structural reforms; many countries are decentralizing functions and budget planning to subnational entities and/or developing universal health care (UHC) schemes, which may or may not include family unit planning.

2d, each donor also takes a varying approach to land transitions, using different criteria and processes. These processes often do not align across donors and impact the outlook for transition success differently in each land. Family planning assistance is frequently project-focused, programmed off-upkeep, and channeled through nongovernmental entities. These approaches reflect the principal donors' broad structural features, and the historic approach has important implications for the design and eventual success of any state transition.

As the USG looks to transition partner countries away from traditional assistance it will be of import to:

1. Continue to maximize coordination amongst donors and other partners at a global level to minimize the possibility of a state experiencing an precipitous change in support and a major financing gap;
2. Develop a "continuum" approach that recognizes where countries are in terms of their development trajectory and unmet need, and integrates each country'southward unique vulnerabilities into assessments; and
3. Learn from by transitions by USAID, many lessons of which come up from USAID family planning programs, and by other donors (e.g., more recently, Gavi).

Key Ideas and Proposals

Overarching Discussion Goal: Focus on transparent and footstep-by-step transitions, with the goal of sustainable success rather than reacting in haste to (what nosotros hope will be) short-term funding challenges, especially in terms of USG back up.

Participants identified a number of means to work towards this overarching goal, including:

1. ENHANCE TRANSPARENCY AS A STRATEGY TO REDUCE UNCERTAINTY AND Increment THE LIKELIHOOD OF SUCCESS.
   • Participants emphasized building on the Modernizing Foreign Assistance Network (MFAN) recommendations.^[27]
   • It is critical to envision what transition success looks like across multiple dimensions such as financing, commodities, social norms, health and non-health outcomes. Some examples to consider:
     • Aim to become the closest countries to fully transition from all donor support or transition abroad from USG support as a first pace?
     • Maximize health improvements? (e.chiliad., Wellness Systems Strengthening Approach)
     • As a related discussion, also enquire: are these dimensions and outcomes the same or different compared to current FP2020 goals?
   • There was accent on the demand for USAID to share, talk over, and publicize the transition strategy with a broad range of stakeholders—implementing agencies, partner countries, other donors, civil society, etc. All the same, it is of import to admit the following:
     • There are still several unknown dimensions of possible transition scenarios. Will transition exist specific to family planning programs, health sector-specific, or take on whole of country transitions?
     • Each of the scenarios (family planning-specific and health-sector wide) would differ in approach and in turn bear on each other.
   • There was besides discussion on the importance of costing and evaluation as part of thinking through a transition plan. Costing is of import for potential alternative funders to sympathize what they are taking on. Evaluation is important for understanding exactly what results might need to exist sustained every bit part of a transition.
2. REVISIT CRITERIA TO Be USED AT Dissimilar POINTS Along THE TRANSITION CONTINUUM FOR FAMILY PLANNING PROGRAMS.
   • Participants expressed the need to identify possible trigger indicators/thresholds beyond what USAID currently considers (full fertility rate and modernistic contraceptive prevalence rate) ^[28] to beginning a conversation about transition.
   • Quantitative criteria suggested include:
     • On youth bulge and/or security: share of population < 18 years old, or population density
     • On equity: coverage among the poor, geographic equity (urban-rural)
     • On quality: discontinuation rates
     • On health and outcomes for women and girls: births to < 18-year-old girls, child wedlock
     • Domestic investments for family planning
     • Un/underemployment rate
   • Qualitative criteria suggested include:
     • Demonstrated commitment or political will to scale or reach the poor as role of the broader enabling environment
     • Social norms/need for family planning
     • Ability of private sector to rapidly expand coverage in middle-income countries
     • Readiness to implement or scale programs across both public and private sectors
     • Readiness (social and fiscal) of citizens to take on family unit planning costs themselves
   • Participants as well mentioned building-in a plan for post-transition monitoring, with defined indicators, in the initial strategy.
   • The comparison to MCC-style threshold criteria might too utilize hither; that is the possibility of setting appropriate indicators with thresholds for when a country is ready to begin give-and-take about the transition process.
3. INCREASE DOMESTIC SPENDING ON FAMILY PLANNING, Particularly IN LOWER-MIDDLE-INCOME COUNTRIES AND/OR TOP TRANSITION CANDIDATES.
   • Among other options, participants stressed that donors should create incentives for increased domestic spending on global health priorities, including family planning, taking an integrated approach.
     • While co-financing has been used as a strategy for incentivizing domestic country spending, it is not yet function of the family planning mural. It is worth noting, however, that many global health funders similar Gavi, the Global Fund, and the Global Financing Facility (GFF) do employ co-financing requirements as 1 part of a transition strategy.
     • Innovative financing (e.g., Development Touch on Bonds, Greenbacks on Delivery Aid) offers one possibility; doing this every bit part of broader health reforms in-country is another option.
   • Establishing a "hand-off" to the GFF for countries at the tiptop of the Due south-curve was as well mentioned. The proposal would be that USAID funds the GFF to transition family unit planning, and accountability for family planning becomes on-upkeep.
   • Participants discussed the need to build an integrated "enquire" to governments across global health priorities, which considers the fiscal infinite that is realistically available. Rather than aspirational, participants felt this approach could be operationalized by, for example, combining with multi-year funding commitments as in PEPFAR's S Africa Partnership Framework. I hypothesis is that this would result in less competition with other global wellness priorities and would besides open the possibility of synergies with other funding streams.
     • The "ask" should include a stiff and well-integrated investment case, going across health to include development more broadly, and targeted to upkeep-holders in national and subnational governments. While this is beingness done in some contexts, efforts are somewhat ad-hoc and not connected to the upkeep resource allotment process.
4. TAKE A "TOTAL Market APPROACH" TO TRANSITION.
   • As USG back up is reduced, plan for sustaining and/or increasing provision by individual, not-for-profit, and NGO partners, including faith-based providers, that help ensure admission to loftier-quality voluntary family planning programs. Drawing on experiences in Latin America was suggested.^[29]
   • Relatedly, building capacity for governments to contract with such providers (notation: also discussed with PEPFAR in the context of partnership frameworks); this may include building capacity of payers/purchasers as one role of broader wellness reforms.
5. TO REINFORCE AND BUILD UPON LESSONS FROM PREVIOUS EXPERIENCES, Set A PROJECT, INITIATIVE, OR CLEARINGHOUSE ON TRANSITION (OR BUILD THIS INTO FP2020).
   • USAID has a strong track record of successfully transitioning family planning programs in some fifteen countries by planning and preparing for long-term sustainability.
   • Collating, publishing, and discussing lessons learned from by family planning transitions, including USAID transitions more than broadly, as well as past PEPFAR partnership frameworks, could serve every bit a helpful repository. Ane option would be to dedicate a section of the USAID-funded Knowledge for Health (K4H) to transition.^[thirty]
6. RECONSIDER AND STRENGTHEN BROADER APPROACHES AND STRATEGIES TO TRANSITION.
   • Some other issue raised includes working on edifice capacity to shift cultural and social norms related to the adoption of family unit planning—this includes working with traditional leaders, organized religion-based leaders, and others.
   • The thought of staggered transitions with a focus on continued support for programs for immature people and vulnerable, harder-to-achieve communities was discussed.
   • Identifying transitions that experience recidivism during or after their implementation was raised. Taking an intentional approach to responding to backsliding and having a tool kit that includes a range of potential corrective actions would be helpful.
   • Additional suggestions included bringing in "other partners" outside of family planning and extending beyond health circles; using language that resonates exterior internal family planning circles (i.e., tailor terminology for ministries of finance vs. ministries of health vs. US policy audiences vs. other countries, etc.).
   • Prospectively evaluating and developing scenarios, using portfolio review data, creating dashboards of appropriation-obligation calendars, and informing a broad range of partners was mentioned.
   • Use the data collected to concord both donor and partner governments to account, share data and other relevant information with civil society in partner countries and in the US to enhance budget and performance accountability (note: some upkeep work with civil gild organizations is already underway).
   • There was mixed feedback on using the term "graduation."

III. Commodities

Problem Statement and Background

The sustainability of contraceptive bolt provision remains at risk due to uncertainty about hereafter donor back up, particularly from the US. This is further exacerbated by existing challenges including dependence on donors to fund family planning commodities, a lack of alignment across contraceptive supply chains, and the expected rapid growth in demand due to the youth bulge.

Figure 3-A

Source: CGD, "Global Family unit Planning Funding—What Should Funders Be Thinking About Now?," blog, Dec. 20, 2016.

Many countries, especially depression-income countries, go on to depend on donors to finance a large share of family unit planning commodities and related support (e.g., forecasting, procurement, supply concatenation, and logistics). The Reproductive Wellness Supplies Coalition (RHSC) reports that within the 69 FP2020 countries, users directly purchase 58 per centum of bolt.^[31] Slightly less than half (45 pct) are provided through either donor (30 percent) or domestic government (xv percent) financing. The latter represent subsidies that may or may non be targeted to the poor or about vulnerable. In low-income countries, the proportion of bolt provided past donors is much higher, with domestic regime funding accounting for a mere 2 percent (see Figure Iii-A).^[32]

While at that place have been of import advancements in strengthening contraceptive procurement and supply chains, existing mechanisms are non aligned across the health sector and, therefore, not necessarily maximizing efficiencies. In many LMICs, there are all the same parallel supply chains for family planning commodities—and other global health bolt, more broadly. Moreover, reliance on ii major central contraceptive procurers (USAID and UNFPA) introduces both benefits and some risks for the sustainability of family unit planning commodity supplies. In addition to possible reductions in US funding, UNFPA Supplies, which provides almost a quarter of all contraceptive commoditites in FP2020 countries, is facing a meaning funding shortfall. These uncertainties create the impetus to address gaps and harmonize approaches across donors and other key actors.

Despite significant progress in increasing the number of women and girls worldwide using modern contraception in line with the FP2020 goal, analyses advise in that location are still pregnant numbers of women and men who desire to avert pregnancy only are non using a modern method. Moreover, the number of women who rely on modern contraception in LMICs is projected to grow. Projections based on varying growth trajectories suggest there could be between 490 and 550 meg contraceptive users by 2020 in 135 LMICs—this would result in an estimated 37 to 97 million boosted users compared to 2016 levels.^[33] And, about of this need will be concentrated in some of the lowest-income countries, which also have the fewest resource available.

Doubt about time to come donor support introduces substantial risks to meeting the contraceptive needs of the growing number of women and men inbound their reproductive years, peculiarly given donor dependence in high-need lower-income countries. Furthermore, if financing from donors and domestic governments remains flat—or decreases—the cost burden could shift to users who already contribute the largest share to family planning article purchases. Recognizing there is no argent bullet, a set of reinforcing and catalytic approaches that take into account USG uncertainties are needed to meet anticipated increases in demand for family unit planning in the short-, medium-, and longer-term.

Fundamental Ideas and Proposals

Overarching Give-and-take Goal: Advance toward satisfying the need for family planning commodities, while also increasing sustainability and planning for dubiety in time to come donor support.^[34]

Participants identified opportunities to decrease vulnerabilities and increase resilience across donors, domestic governments, and the individual sector (both not-for-turn a profit and for-profit), including:

1. WHILE CHALLENGES Effectually PROCUREMENT AND DISTRIBUTION OF FAMILY PLANNING Commodities ARE RELEVANT TO OTHER GLOBAL Health AREAS MORE BROADLY, SOME COMPLEXITIES ARE UNIQUE TO FAMILY PLANNING.
   • Most—though not all—health commodities are provided equally one production for a specific purpose, due east.thousand., a vaccine for disease prevention or a specific curative drug. In contrast, participants acknowledged that family unit planning programs seek to maximize the number of products bachelor (contraceptive method mix) to meet the wide range of needs across various populations. Furthermore, short-term methods (eastward.g., pills, condoms, and injectables) require continuous, uninterrupted product resupply to clients.
   • While the issue of fragmented and parallel supply chains applies to the global health article landscape more broadly, participants discussed complexities specific to family planning.
     • For case, current capacity to support global family unit planning procurement for the public sector is housed within two major organizations—USAID and UNFPA. Both actors, therefore, are fundamental to the planning and designing of strategies to manage possible "shocks."
     • USAID relies on U.s.a. FDA-approving (or in some cases, approving by a Stringent Regulatory Authority or WHO prequalification) every bit the basis for procurement, while UNFPA uses WHO prequalification and country-level approvals for contraceptive procurement.
   • Managing multiple products and multiple manufacturers for the aforementioned/comparable products (eastward.thousand., implants), which may have unlike lifespans and specialized procedures for insertion/removal, creates added complexities.
   • One overarching point was that the quality of family planning commodities is of import and needs to be integrated into all proposed approaches.
2. ENHANCE COLLABORATION AROUND STRATEGIC Resources Allocation FOR FAMILY PLANNING COMMODITIES, OVER THE SHORT-, MEDIUM-, AND LONG-TERM.
   • In the curt-term, participants stressed the need to enhance efficiencies at the global level by increasing information sharing and synchronizing strategic planning among the leadership of existing global platforms, including the FP2020 Reference Group, the RHSC Executive Commission, the GFF Donor Committee, as well as others outside the family planning space.
     • I suggested idea was to commission brusque- to medium-term contingency plans to prioritize donor resources available for family planning commodities from existing sources, likewise equally newly available funding streams, such as SheDecides.
       • Information technology will be important to coordinate outreach and fundraising efforts to cover firsthand and anticipated mid-term gaps.
       • This approach should also recognize that coordination is most effective when there is directly engagement by conclusion-making entities (e.k., governments, providers from the private and religion-based sectors, donors, etc.) to link decisions with financial flows.
   • Another proposal was to amend agreement of GFF's electric current, and potential time to come, intersections with family planning commodity provision.
     • While GFF does not currently procure family planning commodities, closer engagement would be valuable to understand the role that GFF might play vis-à-vis family unit planning commodity procurement, as well as supply chain strengthening and harmonization across the health sector, more broadly.
   • Over the medium-term, participants suggested increasing the transparency of global, land, and local procurement to minimize overpayment, marking-ups, and large price variations, every bit well equally resource misallocation.
   • In the longer-term, resources will be needed to develop new contraceptives, and to innovate new and newly adjusted methods with an eye toward growing the method mix.
3. IDENTIFY OPPORTUNITIES FOR GLOBAL ACTORS TO Further HARMONIZE STRUCTURES AND PLANNING AT THE COUNTRY LEVEL FOR FAMILY PLANNING Commodities—AND EXPLORE OPPORTUNITIES FOR SYNERGIES WITH OTHER HEALTH COMMODITIES.
   • Overall, the importance of focusing on structural factors was mentioned. Among the ideas discussed were ensuring provision of family unit planning commodities is included as office of broader health reforms in-land; continuing and accelerating supply concatenation integration where possible; and supporting, in tandem, larger wellness commodity supply concatenation efficiency, effectiveness, and sustainability.
   • Short-term ideas included:
     • Expanding upon and harmonizing the Country Investment Plan and GFF'southward Investment Example as they relate to family planning bolt;
     • Recognizing the role of decentralized decision-making at the country level, formally documenting its impacts on commodity forecasting, procurement, and supply concatenation systems; and
     • Defining key indicators that demonstrate when countries have matured both in terms of social norms and private sector capacity, with an eye toward increasing private sector service delivery as a share of contraceptive commodity provision (e.g., Indonesia is ane example of a mature middle-income country).
   • Medium-term ideas included:
     • Strengthening private sector procurement in select settings, maybe by expanding implementation of successful models of pooled procurement designed to back up the private sector (both not-for-profit and for-profit). Examples include MedSource in Kenya and DoctorStore in Republic of india (which includes online shopping), available to individual providers.
     • Prioritizing donor and country financial flows to essential components of family planning bolt and supply chains. This includes supply chain management information systems (MIS), data collection, and analysis, which should be considered an of import public good.
     • Ensuring acceptable back up to the human capacity needed to manage existing/new Information technology approaches and to analyze data for quality, and accurate analyses to support critical decision-making.
   • Over the longer-term, participants mentioned continuing efforts to simplify and harmonize regulatory approval to amend production admission, especially across sub-Saharan Africa, and to facilitate product move across borders to maximize flexibility of global suppliers to fill supply gaps.
     • Early lessons from PEPFAR and other organizations in addressing price and regulatory hurdles with ARTs should exist reviewed and incorporated, as applicable.
4. Back up ASSESSMENTS TO Meliorate Sympathise THE OVERALL Commodities Mural AND Place POTENTIAL GAPS AND POSSIBLE EFFICIENCIES.
   • Participants acknowledged the value of existing RHSC studies at the global level, but also pointed to outstanding questions around defining the entirety of the market and analyzing investments in terms of Couple Years of Protection (CYP) and changing method mixes, which are increasingly maturing to expand provision of long-interim reversible contraceptives (LARCs).
   • At the national level, marketplace segmentation within countries will often crave better data than are currently available; a more holistic understanding of public, private, organized religion-based, insurance schemes, etc., is needed.
   • Overall, there is a continued gap in understanding who the market is failing and designing effective responses in this space; management information systems are a critical link between service demand and projected need.
   • Proceed to build on ongoing analyses of Southward-curve country status and demographics to predict global method mix need and inform national and global marketplaces (eastward.one thousand., Republic of kenya is a leader in this process).
     • Linking demographic and Southward-curve analyses will be important to provide mid-term estimates of global demand for LARCs.
   • Increase communication and outreach to experts and policymakers to reinforce the technical and financing leadership office the USG plays equally well equally the expected increase in demand for family unit planning in the coming years.
5. ENHANCE PROCUREMENT COORDINATION Across PUBLIC AND Individual SECTORS TO FURTHER IMPROVE PRICING AND ENSURE CONTRACEPTIVE SUPPLY SECURITY AS Demand GROWS.
   • In the short-term, it could be beneficial to explore procurement and broader supply concatenation- related lessons from other global entities and mechanisms including, but not limited to, Gavi and the Global Fund. Some specific suggestions are every bit follows:
     • Coordinate a learning meeting betwixt Gavi, the Global Fund, and family planning procurers to share lessons learned.
     • Set the stage for decision-making by defining questions and related indicators to make up one's mind if and how to design future global market strategies in family planning to support procurement in the public and private sectors.
   • Committee studies and assessments to sympathize the potential benefits and costs of pooled procurement mechanisms. Information technology would be important to understand if/how such approaches could help strengthen relationships with contraceptive commodities manufacturers, secure better prices, and ensure supply security in the public and private sectors.
     • Draft a gear up of scenarios for potential pooled procurement approaches to present to FP2020, RHSC, and GFF for consideration.
     • Define a study to model a "Gavi-type" approach to provide global market and long-term symbiotic partnership with manufacturers to ensure continuous supplies of commodities.
   • Considering the private sector is the primary source of bolt in many centre-income countries, information technology would also exist important to written report and better empathise possibilities for centralized procurement for the "whole of private sector."
   • Where feasible, participants discussed the possibility of introducing commodity co-financing for highly dependent partner countries in the medium-term. Some outstanding questions to consider:
     • How to practice this if not via UNFPA?
     • Possible stand up-alone platform alongside USAID procurement that allows co-financing or buy-ins to obtain access to prices?
     • New procurement public-private partnership that USAID could buy into?
   • When appropriate to the environment, participants also suggested considering other financing mechanisms to back up local procurement, such as guarantor processes (insurers)?
     • Farther, how could this be balanced by local/regional manufacturing capacity as role of economic development and development sustainability?
   • For all approaches, discussions focused on matching the best country candidates for testing novel interventions that decrease the demand for external financing.
6. EXPLORE THE POSSIBILITY OF A "GLOBAL PLANNING SUMMIT" ON FAMILY PLANNING Commodities.
   • As planning for bolt is a medium- to long-term process, at that place was discussion effectually the possibility of a global planning height to help ensure that contraceptive supply grows commensurately with demand. The purpose would exist to review the status of global manufacturers and suppliers, and possibly to design medium- to long-term approaches for meeting projected growth in contraceptive demand. In add-on to the key public sector procurers, participants suggested coordination with larger entities supporting private sector providers, such as insurers and groups like MedSource in Kenya and DoctorStore in Republic of india. By expanding the groups engaged, the global summit could contribute to a global "whole of market place" agreement of manufacturing capacity and opportunities to increase efficiencies in procurement and logistics management for family unit planning commodities.

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[ii] For more than information, come across CGD'due south Aligning to 2020 Working Group Report (Silverman R, Glassman A, Aligning to 2020: How the FP2020 Core Partners Can Work Better, Together, Middle for Global Development, 2016. Available at: https://www.cgdev.org/sites/default/files/Aligning-to-2020.PDF).

[3] For an overview of current efforts to rails domestic regime expenditures for family planning meet Track20's report (Stover J, Chandler R, Expenditures on Family Planning in FP2020 Focus Countries in 2015, Track20, December 5, 2017. Available at: http://www.track20.org/download/pdf/Expenditures_Assessment_12.5.17.pdf).

[8] Kaiser Family Foundation analysis of data from OECD CRS database, accessed January 8, 2018.

[12] For more than information, refer to USAID'south Family Planning Plan Overview (USAID, Family Planning Program Overview, Apr 2013. Available at: https://www.usaid.gov/sites/default/files/documents/1864/fp_overview.pdf). In 2003, an initial set of 13 priority countries was selected based on USAID'southward allocation formula; 11 countries were added to the priority list under the Obama administration'due south Global Health Initiative. More details tin be establish on folio 8 of CGD'southward Working Group Written report (Silverman R, Glassman A, Aligning to 2020: How the FP2020 Core Partners Can Work Improve, Together, Center for Global Development, 2016. Available at: https://www.cgdev.org/sites/default/files/Aligning-to-2020.PDF).

[19] For a more detailed description, refer to Track20's report on family planning expenditures (Stover J, Chandler R, Expenditures on Family Planning in FP2020 Focus Countries in 2015, Track20, Dec 5, 2017. Bachelor at: http://world wide web.track20.org/download/pdf/Expenditures_Assessment_12.5.17.pdf).

[20] Experience in Latin America shows that progress of family planning programs was sustained post-obit USAID graduation and stage-out, driven by institutionalizing family planning in the public, NGO and private sector. Many governments increased procurement budgets or adult line items, and sustained their commitments over the years. Run into pages 54-55 in Measure out Evaluation's report on Family Planning in Latin American and the Caribbean (Bertrand J, Ward Five, Santiso-Galvez R, Family Planning in Latin America and the Caribbean: The Achievements of fifty Years, MEASURE Evaluation, 2015. Available at: https://www.measureevaluation.org/resources/publications/tr-15-101).

[21] More information can be institute in a UNICEF press release (UNICEF, New funding will permit countries to secure sustainable vaccine supplies and reach children more quickly, December 13, 2017. Bachelor at: https://world wide web.unicef.org/media/media_102311.html).

[23] More data on the International Finance Facility for Immunization can be institute at: https://www.iffim.org/.

[25] Commitments from three countries, India, Bangladesh, and Republic of indonesia account for the lion's share of the $4 billion pledged by lower-middle-income land governments; though it is important to annotation that some countries have not nevertheless delivered on commitments made at the 2012 Summit. For more information, refer to a CGD blog (Silverman R, Family Planning Summit Raises Much-Needed Funds. At present It'south Time for Donors to Stop Existence Polite and Commencement Getting Real, Center for Global Evolution Global Wellness Policy Blog, July 13, 2017. Bachelor at: https://world wide web.cgdev.org/blog/family-planning-summit-raises-much-needed-funds-at present-its-fourth dimension-donors-stop-being-polite) and a Devex commodity (Edwards South, How meaning were the pledges at the London Family Planning Summit?, Devex, July 26, 2017. Bachelor at: https://world wide web.devex.com/news/how-meaning-were-the-pledges-at-the-london-family-planning-meridian-90688).

[28] Per USAID'southward current strategy to transition family unit planning programs, as outlined in a 2006 technical annotation, the trigger indicators used to offset the process are total fertility charge per unit less than or equal to 3.4 and modern contraceptive prevalence rate 48 per centum or greater. USAID's Office of Population and Reproductive Health is currently revising its strategy. In add-on, USAID is too developing agency-broad transition metrics.

[29] Examples of countries in the LAC region that have successfully graduated from USAID Family Planning assistance include Brazil, Chile, Republic of colombia, Mexico, Jamaica, El Salvador, Nicaragua, Honduras, Peru, Paraguay, and the Dominican Republic. Refer also to Mensurate Evaluation'south 2015 report (Bertrand J, Ward Five, Santiso-Galvez, Family Planning in Latin America and the Caribbean area: The Achievements of fifty Years, MEASURE Evaluation, 2015. Bachelor at: https://www.measureevaluation.org/resource/publications/tr-15-101).

[32] Gauge compiled by USAID, based on Avenir Health data and Global Contraceptive Commodity Gap Analysis Reproductive Wellness Supplies Coalition, 2016. For more than data, refer to the CGD web log on family planning funding (Silverman R, Global Family Planning Funding – What Should Funders Exist Thinking Near Now?, Center for Global Development Global Wellness Policy Blog, Dec 20, 2016. Bachelor at: https://world wide web.cgdev.org/weblog/global-family-planning-funding-what-should-funders-be-thinking-nearly-at present).

[34] In line with FP2020 indicator 4: "Per centum of women whose demand is satisfied with a modern method of contraception."

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