Countdown 2015- Strategic Options for greater European Investment in Reproductive Health Supplies

Publication date: 2007

Strategic Options for Greater European Investment in Reproductive Health Supplies Produced by Roger Drew for Countdown 2015 Europe on behalf of Interact Worldwide November 2007 1 Table of Contents Executive Summary 3 Recommendations 5 Introductions 6 Evidence On Global Reproductive Health Supplies Gaps 6 Evidence Of Gaps In Supply 6 Gaps In Capacity 7 Causes and Consequences of Supply Gaps 8 Resource needs estimates for Sexual and Reproductive Health, Including RH Supplies 8 The cost of achieving universal access to Reproductive Heath 8 The cost of achieving MDG5 on Maternal Health 9 The cost of achieving the SRH components of universal access to HIV prevention, treatment, care and support 10 The cost of SRH supplies 10 How can these costs be met? 10 Performance of European countries on financing Sexual and Reproduction Heath and Reproductive Health supplies 13 Donor funding for Sexual and Reproductive Health 13 Funding for RH supplies 15 Focused Governments – Actions and Financing 16 The European Union and European Commission – actions and financing 19 Funding to International Organisations 21 Options for making progress toward greater investment in Reproductive Health supplies 22 Financial targets 22 Mechanisms for enhancing expenditure 23 The potential for the International Health Partnership 25 The Role of the Global Fund to fight AIDS, TB and Malaria 26 Review of recommendations 27 Abbreviations 28 References 29 2 EXECUTIVE SUMMARY Countdown 2015 Europe is a partnership of NGOs concerned with ensuring the following commitments to sexual and reproductive health (SRH) are fulfilled: x In 1994, the International Conference on Population and Development (ICPD) adopted an ambitious 20-year Programme of Action focused on individuals’ needs and rights. It was built on the cornerstones of gender equality, eliminating violence against women and ensuring women’s ability to control their own fertility. x In 2000, the world committed itself to a set of eight ambitious development goals to be achieved by 2015, the Millennium Development Goals, which focused on a set of barriers to overcome extreme poverty. x At the World Summit in 2005, global leaders resolved to add universal access to reproductive health by 2015 to the MDG targets. In 2006, this commitment was endorsed by Ministers of Health of African Union member states. x In 2006 the United Nations General Assembly committed to adopted the goal of universal access to comprehensive HIV and AIDS prevention programmes, treatment, care and support by 2010. x In October 2007, the United Nations General Assembly adopted a set of indicators for tracking progress on universal access to reproductive health by 2015 including addressing contraceptive prevalence and the unmet need for family planning. None of these targets will be met, unless urgent action is taken to ensure the sustained availability of reproductive health supplies. Reproductive health supplies (RHS) are not just condoms and other contraceptives. According to UNFPA, they refer to ‘all the essential equipment, commodities and medicines required for sexual and reproductive health, maternal and neonatal health and for effective responses to HIV and AIDS’. An inter-agency list of essential medicines for reproductive health has been produced. Currently, there is evidence of massive gaps between the need for and the availability of these supplies: x In 2003, a total of 137 million women, who did not want to have another child in the next two years, were not using contraception, that is, their need for contraception was unmet x In 2005, UNFPA’s Thematic Trust Fund for Reproductive Health Commodity Security responded to requests from over 51 countries and disbursed over US$30m for emergency supplies to avoid imminent stockouts Different estimates have been made of the funds needed to bridge these gaps. In 2005, WHO estimated that an additional US$6.1b would be needed by 2015 to improve maternal health as envisaged in MDG5. However, these figures did not include existing amounts being spent or a full range of family planning and reproductive health services. The estimated cost of achieving the ICPD Programme of Action is currently being revised as original costing did not fully account for the scale up of SRH services requires for the response to the HIV and AIDS pandemic. UNAIDS recently provided two scenarios for funding scale-up towards universal access to HIV prevention, treatment, care and support. In order to achieve universal access by 2010 would require US$42.2b in 2010 and US$54b in 2015. To undertake a slower phased scale-up towards universal access would require US$28.4b by 2010 and US$49.5b by 2015. Thus, the best available estimates indicate that, to achieve universal access to reproductive health and comprehensive HIV and AIDS services, US$29.8b will be needed by 2010 rising to US$35.8b by 2015. Given the limit of domestic resources available in developing countries for health responses international donors need to provide one third of these funds, that is, US$9.9b by 2010 and US$11.9b by 2015. Although, since 2001, donor funding for sexual and reproductive health has risen dramatically, this is mostly due to the response to HIV and AIDS. Funding for basic reproductive health services has 3 changed little over that time and funding for family planning services has declined. Nevertheless, some donor countries, e.g. Sweden, the Netherlands and Denmark have performed extremely well. Not only have they met the target of providing 0.7% of their Gross National Income (GNI) as Official Development Assistance (ODA), they have also committed a significant proportion of this ODA to SRH. For example, in 2004, the Netherlands provided more than 10% of its overall ODA to sexual and reproductive health. Other donors, such as the UK, have massively increased their financial commitment to sexual and reproductive health, including particularly the response to HIV and AIDS. Others, e.g. France and Germany, could do more. The European Commission’s performance has been disappointing. The little support that was being given has declined. This is not in keeping with the commitments of the Cotonou Agreement and the European Consensus on Development. The environment in which aid is provided is increasingly complex with a shift away from specific SRH projects/programmes towards sectoral and general budget support. In addition, there has been a growth of funds available through Global Health Partnerships, such as the Global Fund to Fight AIDS, TB and Malaria. Development aid needs to be provided more effectively. The Paris Declaration on Aid Effectiveness provides principles for doing this. This involves priorities and budgets being set and owned nationally, and donors aligning their efforts around these. Increasingly, decisions about resources for reproductive health, in general, and reproductive health supplies, in particular, will be made nationally, e.g. in national health plans and expenditure frameworks in developing countries. For this reason, programmes, such as UNFPA’s Global Programme for Enhancing Reproductive Health Commodity Security, focused on facilitating national efforts to prioritise and mainstream reproductive health supply security in health plans and expenditure frameworks, are of critical importance. 4 RECOMMENDATIONS 1. FULL FUNDING - Best available estimates indicate that the funding needed to achieve universal access to reproductive health and comprehensive HIV and AIDS services is US$29.8b in 2010 rising to US$35.8b in 2015. Countdown 2015 Europe calls on donor governments to take urgent action to provide one third of these resources and meet targets of US$9.9b in 2010 and US$11.9b by 2015. 2. INCREASE ODA – To achieve universal access to reproductive health, including the call of parliamentarians from G8, European and African countries for 10% of ODA to go to sexual and reproductive health, Countdown 2015 Europe calls on donor governments to provide 0.7% of their Gross National Income as ODA. 3. ENSURE COMMODITY SECURITY – To date, there has been little focus on ensuring that RHS are prioritised and mainstreamed in national health plans and expenditure frameworks. UNFPA, the Reproductive Health Supplies Coalition and others are focused on enhancing reproductive health commodity security. Countdown 2015 Europe calls upon donor governments to ensure their bilateral and multilateral channels similarly prioritise expenditure on reproductive health supplies. 4. ADDITIONALITY – Countdown 2015 Europe welcomes the increased levels of funding for sexual and reproductive health and reproductive health supplies which have been made available within the response to HIV and AIDS. We urge donors to ensure that funds for HIV and AIDS are not being provided at the expense of addressing universal access to reproductive health. 5. SRH-HIV and AIDS INTEGRATION – Countdown 2015 Europe calls on European donors to increase effective use of resources through appropriately integrated and linked responses to sexual and reproductive health and HIV and AIDS. Such responses need to be aligned within national frameworks. Investments in SRH need to mainstream HIV and AIDS, and investments in HIV and AIDS should be appraised for appropriate inclusion of SRH. 6. HEALTH SYSTEMS AND HEALTH WORKFORCE – Universal access to reproductive health requires strong health systems. Countdown 2015 Europe calls on donor governments to ensure that aid instruments, including the International Health Partnership, are used to provide long-term, sustainable investment in health systems strengthening, particularly for significant investment in human resources for reproductive health. 7. EDUCATION SECTOR RESPONSE TO SRH – Most of the focus on barriers to access of RH supplies currently centres on lack of commodities but an equal or perhaps larger barrier to access is in terms of demand. Countdown 2015 Europe calls on donors to fund comprehensive evidence–based sexuality education to help educate the public on SRH and create demand for the provision of RH supplies. 8. NATIONAL PRIORITIES – The Paris Declaration on Aid Effectiveness outlines the need for increased national ownership of development efforts and alignment of donor efforts around national plans. Countdown 2015 Europe calls on donors to; consider effects on SRH when assessing the effectiveness of aid, including general and sectoral budget support; work with government to ensure that national plans include robust SRH indicators; ensure RHS budget lines are implemented; and annual reviews indicate expenditure against these goals. 9. EUROPEAN COMMISSION – Countdown 2015 Europe is extremely concerned that the European Commission’s support for sexual and reproductive health is declining, contrary to commitments made in the European Consensus on Development. Urgent measures are needed to ensure that funds for reproductive health are prioritised in country and thematic programmes. 10. GLOBAL FUND – Resources provided for the response to HIV and AIDS by the Global Fund have been significant and increasingly recipients seek to leverage benefits to SRH and wider health services. Countdown 2015 Europe calls on the Global Fund to be explicit in its support for SRH-HIV and AIDS integration, beginning by approving a Round 8 Call for Proposals that outlines the funding opportunities for SRH programming and reproductive health supplies. 5 INTRODUCTION Countdown 2015 Europe is the label under which ten European NGOs will work together with their partners to increase European investment in reproductive health supplies1. Countdown 2015 Europe is funded by a grant from the Bill and Melinda Gates Foundation through the International Planned Parenthood Federation European Network. The members of the Steering Committee are: x Deutsche Stiftung Weltbevölkerung (German Foundation for World Population), Germany x Equilibres & Populations, France x European Parliamentary Forum, Brussels x Interact Worldwide, United Kingdom x IPPF European Network, Brussels x Marie Stopes International, Brussels x The Swedish Association for Sexuality Education, Sweden x Sex & Samfund (Danish Family Planning Association), Denmark x Vaestoliitto (Family Federation of Finland), Finland x World Population Foundation, Netherlands This document is the inception publication of a Countdown 2015 Europe project, Europe Champions Reproductive Health Worldwide II: Tackling the Supply Challenge (IPPF EN et al., 2007c). This project aims to increase financial support as well as improve European coordination and coherence on reproductive health supplies in order to narrow the gaps between the needs, demand and availability of the necessary supplies and secure reproductive health as an essential step toward achieving the MDGs. This report provides baseline evidence, analytic rationale, recommendations and strategic options for consideration by European donors, other policy makers and colleagues in development. It is divided into three main sections: evidence of gaps in reproductive health supplies; resources needed to fill those gaps; options for greater investment. Recommendations to policy makers are fully stated in the Executive Summary and briefly reviewed at the conclusion of the document. EVIDENCE ON GLOBAL REPRODUCTIVE HEALTH SUPPLIES GAPS This section considers the evidence of gaps in the global provision of reproductive health supplies. This includes unmet contraceptive need, low utilisation of poorly-supplied health facilities and requests for emergency supplies to avoid stock outs. It then considers gaps in capacity and the causes and consequences of supply gaps. Evidence of Gaps in Supply Most recent estimates are that 137 million women globally have unmet need for contraception (Sonfield, 2006), that is they do not want another birth in the next two years but are not using contraception. 64 million were using traditional family planning methods2. As a result, more than a quarter (29%) of women in developing countries had unmet need for modern contraception. This is particularly severe in sub-Saharan Africa where almost half (46%) of women at risk of unintended pregnancy are using no method of family planning and almost two thirds (63%) are not using modern methods of contraception (Singh et al., 2004; UNFPA, 2004). Lack of health facilities, equipment, health personnel and medicines all contribute to reduced/delayed utilisation of health services and reduced quality of those services. In the case of maternal health services, these factors have been identified as major causes to delays in receiving emergency obstetric 1 The terms reproductive health supplies and reproductive health commodities are used interchangeably in the literature on this topic. The former term is used in this document except where directly quoting from other documents or referring to names or organizations / programmes. 2 Such as periodic abstinence and withdrawal as well as breastfeeding infertility 6 care3. These delays are major contributors to maternal deaths (World Bank, 2002). The importance of reproductive health supplies is recognised in some countries, e.g. Uganda, where the most commonly used injectable contraceptive, Depo-Provera, is one of six indicator drugs for monitoring stock outs. However, information on stock outs remains poor because of missing stock cards, incomplete reporting and calculation errors (Chattoe- Brown and Bitunda, 2006). Nevertheless, stockouts of reproductive health supplies at clinic level are reported to be common (PAI, 2004 and see Box 1). Many countries are making emergency requests for support to obtain reproductive health supplies. For example, in 2002, UNFPA assisted 33 countries with reproductive health supplies to a value of US$1.5m (UNFPA, 2002). In 2005, UNFPA’s Thematic Trust Fund for RHCS responded to requests from over 51 countries for emergency response activities. This led to disbursements of over US$30 million to directly address shortfalls. UNFPA’s Global Programme to Enhance Reproductive Health Commodity Security (RHCS) has one of its three themes focused on funding for emergency responses (UNFPA, 2006a). Box 1: Gaps in Reproductive Health Supplies: An Example from Northern Uganda A recent study in Northern Uganda (Krause, 2007) concluded that there was a significant gap in the coverage of health facilities and a dearth of qualified health care workers. Stock outs of essential reproductive health materials and supplies were both reported and directly observed in some health facilities. Female condoms were not available and some drugs had passed their expiry dates. Conversely, where supplies were available, uptake of reproductive health services increased. Overall, the study concluded that ‘family planning services were very weak and women were desperate to access birth control.’ Gaps in Capacity UNFPA’s Global Programme on RHCS identifies two elements of the gap in supplies. First, there is the gap in availability of supplies themselves. Second is the gap in capacities to deliver reproductive health services, in general, and these supplies, in particular. Historic efforts have focused largely on the first gap but a sustainable solution will require the capacity gap to be addressed also. The need for capacity development currently significantly exceeds ‘commodity gaps’ and therefore demand higher priority in national programmes (UNFPA, 2006a). Thus, the main focus of the Global Programme on RHCS is now on facilitating national efforts to prioritise and mainstream reproductive health supply security into national health policy and budget framework. Currently, this approach is being applied in six4 ‘proof of concept’ countries with plans to add more5. This approach fits well with Sector Wide Approaches, with the Paris Declaration on Aid Effectiveness and current aid architecture all increasingly focusing on country-led approaches and use of new aid instruments. In response to the fact that shortages of essential reproductive health commodities are growing, the Reproductive Health Supplies Coalition (RHSC) was founded to provide global leadership in making essential reproductive heath available to developing and transitional countries. The RHSC comprises a forum of Multilateral organisations, Bilateral donors, private foundations and NGOs in which to develop collaborative strategies and exchange technical information. The three working groups: Systems Strengthening, Market Development Approaches and Resource Mobilization and Awareness are working to provide countries with increased resources and technical capacity to scale up RH commodities. 3 All five major causes of maternal mortality; haemorrhage, sepsis, unsafe abortion, hypertensive disorders and obstructed labour can be treated at a well-staffed, well-equipped health facility. Expanding access to emergency obstetric care requires that all women and newborns with complications have rapid access to well-functioning facilities, whether a mobile health unit, district hospital or upgraded maternity centre. 4 Burkina Faso, Ethiopia, Ghana, Mongolia, Mozambique, and Nicaragua 5 Including Yemen 7 Causes and Consequences of Supply Gaps Causes of shortages in reproductive health supplies are varied and include a rising number of people of reproductive age, increasing demand for contraceptives, increases in transmission of HIV and inadequate management capacity (IPPF, 2007a). These gaps in supplies have serious consequences. They contribute to maternal mortality, hinder the implementation of effective SRH programmes and undermine progress towards international commitments, such as the Millennium Development Goals (MDGs) and those made at the International Conference on Population and Development (ICPD) (Singh et al., 2004; Supply Initiative, 2004a and 2005; UNFPA, 2005a; IPPF, 2007a). RESOURCE NEEDS ESTIMATES FOR SEXUAL AND REPRODUCTIVE HEALTH, INCLUDING RH SUPPLIES This section considers resource needs estimates for sexual and reproductive health in three specific areas - achieving universal access to reproductive health; improving maternal health and achieving the SRH components of universal access to HIV prevention, treatment, care and support. It then considers issues relating to costs of RH supplies specifically before concluding with discussion of how identified costs can be met. The Cost of Achieving Universal Access to Reproductive Health The 1994 International Conference on Population and Development (ICPD) adopted a 20-year Programme of Action focused on individuals’ needs and rights and built on the cornerstones of gender equality, eliminating violence against women and ensuring women’s ability to control their own fertility. At the World Summit in 2005, world leaders resolved to achieve universal access to reproductive health by 2015 and committed to integrate the goal of access to reproductive health into national strategies to attain the MDGs (UNFPA, 2005c). This was adopted by the UN General Assembly in 2006 (ELDIS, 2007). The meaning of universal access to reproductive health and what is needed to achieve this has been explored by a number of authors (e.g. Fathalla et al., 2006, ELDIS, 2007). In October 2007, the UN General Assembly adopted a revised set of indicators for monitoring progress on the MDGs, which include a more explicit focus6 on reproductive health (UN General Assembly, 2007). Following the production of resource estimates for reproductive health and population for the International Conference on Population and Development held in Cairo in 1994, a great deal of work has been done on this topic (e.g. Fraser et al., 2002; Singh et al., 2003; UNAIDS, 2005; WHO, 2005; Bernstein and Vlassoff, 2006, Ethelston and Leahy, 2006; Millennium Project, 2006). Results from this work are summarised in Table 1. Estimated needs are now considered to be higher than when the original ICPD estimates were made. Reasons for this include more explicit figures for system costs; improved data on costs of emergency obstetric care and other maternal health interventions; an expanded list of HIV prevention interventions; better methods for collecting health and population policy data needs; and better approximations of the costs for scaling up to universal coverage of services (Bernstein and Vlassoff, 2006). 6 This included achieving universal access to reproductive health by 2015 as an indicator. It also included contraceptive prevalence as an indicator for the target on maternal mortality and indicators on adolescent birth rate, antenatal care coverage and unmet need for family planning for the target on universal access to reproductive health. 8 Table 1: Estimated Annual Cost for Achieving the ICPD Programme of Action (US$b) Components of RH/Population Package 2000 2005 2010 2015 Basic RH services (including family planning) 13.9 19.4 24.4 Sexually transmitted diseases and HIV/AIDS activities 4.1 9.7 11.1 Basic research data and population and development policy analysis 0.3 0.8 0.4 Total 18.2 29.8 35.8 Original ICPD figures7,8 17.0 18.5 20.5 21.7 Cost of RH supplies9 1.84 2.34 2.88 3.43 Drugs and medical supplies 1.01 1.27 1.56 1.84 Contraceptives 0.75 0.84 0.92 0.99 Condoms10 0.08 0.22 0.40 0.60 Data Source: Bernstein and Vlassoff, 2006 except where stated in footnotes The Cost of Achieving MDG 5: Improving Maternal Health A key element of achieving MDG 5 is improving the coverage of maternal and newborn care. The additional cost of doing this in 75 countries was estimated at US$1b in 2006, rising to US$6.1b in 2015. The total additional cost for the period 2006 to 2015 would be US$39b. Of this, almost half (48%) would be for drugs, commodities and supplies, a quarter (25%) for human resources, 22% for health system strengthening and 4% for programme development and support (see Figure 1; WHO, 2005). Figure 1: Breakdown of Additional Costs of Scaling Up Maternal and Neonatal Health Services in 75 Countries 25% 22% 4% 48% Drugs, commodities and supplies Human resources Health system strengthening Programme development and support Data Source: WHO, 2005 These figures are significantly lower than those for providing universal access to reproductive health/implementation of the ICPD Programme of Action. There are two main reasons for this. First, these figures are for additional costs to scale up to meet MDG5 targets, not the total cost required for baseline through target figure. Second, they do not include the costs of a full range of contraceptive needs, only post-partum family planning. 7 Figures for 2000 and 2005 from Euromapping Project, 2007 8 Figures for 2010 and 2015 from UNFPA, 2005b; UNFPA, 2006a 9 UNFPA, 2005a 10 The figures for condoms are lower than in UNFPA, 2005d of US$0.42b in 2000, US$0.49b in 2005 and US$0.55b in 2010. 9 The Cost of Achieving the SRH Components of Universal Access to HIV Prevention, Treatment, Care and Support In 2005, UNAIDS estimated that the global resource requirements for an effective response to HIV and AIDS would be US$14.9b in 2006, US$18.1b in 2007 and US$22.1b in 2008 (UNAIDS, 2005b). Estimates were released in September 2007 on the costs of providing universal access to HIV prevention, treatment, care and support (UNAIDS, 2007b). These vary according to two scenarios. The first, universal access by 2010, would require US$42.2b by 2010 and US$54b by 2015. The second, a phased scale-up to universal access, would require US$28.4b by 2010 and US$49.5b by 2015. There is clearly an overlap between resource needs for universal access to comprehensive services for HIV and AIDS and universal access to reproductive health. However, there are a number of challenges in how these costings inter-relate. Not all interventions included in UNAIDS’ method relate directly to access to reproductive health, as described in the ICPD Programme of Action, e.g. antiretroviral therapy. There have been attempts to try to quantify the proportion of spending on particular HIV prevention interventions that should be included in methods for costing providing universal access to reproductive health (Bernstein and Vlassoff, 2006). The estimated cost of providing the SRH elements of universal access to HIV prevention11 is shown in Table 2. In 2010, US$9b would be needed for the SRH elements of HIV prevention to achieve universal access by that date, whereas US$6.5b would be needed to achieve a phased scale-up. Although this is a possible approach for calculating resource needs, it will be difficult to track spending in this way. If total spending on HIV and AIDS continues to be counted as contributing to improving access to reproductive health, in general, and the ICPD Programme of Action, in particular, there is a risk of creating a false impression of the level of resources available (see Figure 2, p14). However, attempts to disaggregate reproductive health and HIV/AIDS spending risks creating the impression that these issues are separate and unlinked (Fathalla et al., 2006). Concerns have been raised about funding which have contributed to SRH and HIV/AIDS as separate and unlinked service areas. This has been part of the rationale for calls for stronger linkages between reproductive health programmes and responses to HIV and AIDS (Druce et al., 2006). The Cost of RH Supplies UNFPA has produced detailed estimates of the costs of providing sufficient RH supplies to implement the ICPD Programme of Action (UNFPA, 2005a; see Table 1, p9). These were estimated to be US$1.84b by 2000, US$2.34b by 2005, US$2.88b by 2010 and US$3.43b by 2015. The proportion needed for drugs and medical supplies would remain constant at 55%. The proportion needed for contraceptives was predicted to fall from 41% by 2000 to 29% by 2015 while the proportion needed for condoms for HIV prevention was predicted to rise from 4% to 18% over the same period12. How Can These Costs Be Met? ICPD envisaged that two thirds of the money required would come from developing countries and one third from donors (Euromapping Project, 2007). This would have meant that the amount required from donors would have been US$5.7b by 2000, US$6.2b by 2005, US$6.8b by 2010 and US$7.2b by 2015 (UNFPA, 2005b). Using the same proportions and revised figures (see Table 1, p9) the new donor targets would be US$9.9b by 2010 and US$11.9b by 2015. Actual figures for 2000 (Singh et al., 2004) indicate that developing countries were financing around three quarters of the cost of sexual and reproductive health services indicating that, at that time, developing countries had made more progress ICPD targets than donors had in terms of providing their proportion of financing. There is evidence, however (Fathalla et al., 2006) that 42% of all expenditure on sexual and 11 The summary paper contains figures for HIV prevention only. It is unclear if other figures are available for other parts of the response to HIV and AIDS which might be considered to have relevance to SRH. 12 These figures need to be considered when seeking to interpret findings such as those presented in Figure 3. 10 11 reproductive health services is actually out of pocket expenditure. Whilst it is recognised that market mechanisms are extremely important in extending access and overall distributive capacity, where such very high proportions of services and commodities are only available on a paid for basis, there is serious concern about equity of access amongst the poor and marginalised. Table 3 shows the split of funds from different donor sources for 2004 with estimates for 2005/6.More than 80% of donor funding came from developed countries in 2004 and this proportion was expected to rise (UNFPA, 2005b). Table 2: Estim ated SR H Elem ents of C osts of A chieving U niversal A ccess to H IV Prevention 2010: Tw o Scenarios (U S$m ) H IV Prevention A ctivity Scenario 1: U niversal A ccess by 2010 Scenario 2: Phased Scale-up to U niversal A ccess M ultiplier for SR H (% ) SR H cost Scenario 1 SR H cost Scenario 2 C om m unication for social and behavioural change 386 257 70 13 270 180 C om m unity m obilisation 135 69 80 108 55 Voluntary C ounselling and Testing 1349 939 90 1214 845 Youth in school 145 108 80 116 86 Youth out of school 633 269 80 506 215 Program s focused on sex w orkers and clients 1542 1420 90 1388 1278 Program s focused on m en w ho have sex w ith m en 1183 1183 90 1065 1065 H arm reduction for injecting drug users 3181 3181 20 636 636 W orkplace 835 382 20 167 76 Program s focused on prisoners 261 261 N ot included 14 N /A N /A O ther vulnerable populations 209 252 15 100 209 252 C ondom provision 900 561 100 900 561 M anagem ent of sexually-transm itted infections 2001 893 100 2001 893 Prevention of m other to child transm ission 662 662 50 331 331 M ale circum cision 157 105 N otincluded N /A N /A Blood safety 359 359 10% 36 36 Post-exposure prophylaxis 4 4 20% 1 1 Safe m edical injections 859 859 0% 0 0 U niversalprecautions 277 123 25% 69 31 TO TA L 15078 11885 9017 6541 D ata Source: Scenario data from U N AID S, 2007b; M ultipliers for SR H from Bernstein and Vlassoff, 2006 13 Referred to as ‘m ass m edia’ 14 M ultiplier table does not have this category – rather it has prevention program s for people living with HIV. 15 It is unclear why the figure for scenario 2 is higher than for scenario 1 12 Table 3: Sources of Donor Funding for Sexual and Reproductive Health Services 2004 2005 (est) 2006 (est) Total (US$b) 5.6 6.9 7.8 Developed countries 80% 84% 86% UN System 1% 1% 1% Foundations/NGOs 8% 7% 6% Development Bank Grants 4% 3% 3% Development Bank Loans 6% 5% 5% Data Source: UNFPA, 2005b PERFORMANCE OF EUROPEAN COUNTRIES ON FINANCING SEXUAL AND REPRODUCTIVE HEALTH AND REPRODUCTIVE HEALTH SUPPLIES This section focuses on the performance of a number of European countries16 and the European Commission in financing sexual and reproductive health overall and on supplies. First, it considers these issues in general. It then considers a number of specific issues, including actions and financial provision by the selected European countries and the European Commission, and pledges to UNFPA’s Global Programme to Enhance Reproductive Health Commodities Security. Donor Funding for Sexual and Reproductive Health The amount of funding available for sexual and reproductive health is affected by the amount of funding available as official development assistance (ODA) overall. This issue is not considered in detail in this document17. However brief notes are included here: x The countries of the European Union provide two thirds of ODA overall x Although levels of ODA provided by Development Assistance Committee (DAC) member countries rose steadily to 2005… x …this was due in large part to debt relief and fell in 2006 x The biggest European donors overall are France, Germany and the UK x The biggest per capita donors are Denmark, Luxembourg, the Netherlands, Norway and Sweden, all of whom have met the target of providing 0.7% of their gross national income (GNI) as ODA There are challenges in tracking spending on sexual and reproductive health services (Fathalla et al., 2006). Budgets and expenditure reports may not disaggregate spending on sexual and reproductive health within overall health spending. Issues of how to deal with spending on HIV and AIDS have been discussed earlier (see p11). Figures for donor spending (see Figure 2).on sexual and reproductive health services show this lagging behind ICPD targets until 2004 but exceeding them after this date (UNFPA, 2005b). 16 Denmark, Finland, France, Germany, Netherlands, Sweden and the UK 17 For more detail, see Euromapping, 2007 13 Figure 2: Donor Spending on Sexual and Reproductive Health Services: 1994-2006: Comparison to ICPD Targets (from UNFPA, 2005b) 0 1 2 3 4 5 6 7 8 9 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 ICPD Target for Donor Spending Actual Donor Spending Data Source: UNFPA, 2005b However, almost all of this increase is due to increased funding for responses to HIV and AIDS18, and masks reducing levels of funding for aspects of services including for family planning19. From 2001-04, the percentage of donor spending on SRH services going to HIV and AIDS rose from 39% to 54%, while the percentage spent on family planning fell from 30% to 9% over the same period (UNFPA, 2005b; Euromapping Project, 2007; see Figure 3, p15). Figure 4 shows a similar picture for individual European donors for projected spend in 2006 (UNFPA, 2005b). The percentage of SRH funds to be spent by individual European donor countries on HIV/AIDS ranged from 65-97%20. Overall, donor countries were projected to spend US$6.6b on SRH in 2006, of which 82% would be for HIV/AIDS, 7% for basic reproductive health services, 3% on research and 2% on family planning. As a result, in 2006: x The largest donor supporting family planning in 2006 was the US (61%). Significant European donors were the UK (21%) and Germany (13%) x The largest supporter of basic reproductive health services was the US (34%). Other significant funders included the UK (17%) and the Netherlands (10%) x Almost all research funding for sexual and reproductive health from donors was to from the US (95%) 18 Including provision of condoms and PMTCT within antenatal services 19 Including contraceptives 20 Excluding Finland. Although their projected spend on HIV/AIDS was only 32% of total spending on SRH, this was because almost two thirds (63%) could not be allocated. 14 Figure 3: Donor Spending on Sexual and Reproductive Health Services: 2001-2004: Percentage Spent on Particular Activity Types 0% 10% 20% 30% 40% 50% 60% 2001 2002 2003 2004 Spending on STIs, HIV and AIDS Spending on family planning Data Sources: UNFPA, 2005b and Euromapping Project 2007 Figure 4: Projected Donor Spending on Sexual and Reproductive Health Services: 2006: Percentage on Particular Activity Types by Selected Donor Countries and the European Commission 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Den Fin Fra Ger Net Swe UK EC HIV and AIDS Basic reproductive health services Research Family planning Other/Unknown Data Source: UNFPA, 2005b Funding for Reproductive Health Supplies In 2005, donors provided a total of US$213m for the purchase of condoms and contraceptives (UNFPA, 2005d) compared to an estimated need of at least US$1.06b21 (see Table 1, p8). This had risen from US$133m in 2000 and US$203m in 2004. Of this total, 43% was provided through multilateral organisations22, 39% directly by bilaterals23 and 19% by social marketing organisations/NGOs24. The proportion going through multilaterals increased in 2005 as compared to the entire period 2000-2005, while the proportion going directly through bilaterals fell during the same period (see Figure 5). 21 UNFPA, 2005d has a higher figure for need of US$1.33b 22 Particularly UNFPA 23 Germany, Canada, the UK, Japan and the US 24 DKT, IPPF, MSI, PSI 15 Figure 5: Support for Contraceptive and Condom Supplies by Donor/Agency Type: 2000-2005 0 50 100 150 200 250 2000 2001 2002 2003 2004 2005 US $m Total Bilateral Multilateral Social Marketing Organisations/NGOs Data Source: UNFPA, 2005d Focus Governments – Actions and Financing This section covers the actions and financing of sexual and reproductive health in developing countries by European donors that are the focus of Countdown 2015 Europe. Table 4 presents summary financial data (Euromapping, 2007; UNFPA, 2005b) Euromapping reviewed funding trends by considering total grants to the international NGO IPPF, the Global Fund and UN agencies UNAIDS, UNFPA and UNIFEM as contributing to SRH. This poses the risk of overestimation as most donors would attribute only a percentage of grants towards SRH e.g. Sweden counts 58% of the Global Fund grant to HIV and AIDS. All countries increased their total funding for sexual and reproductive health services by at least 29% between 2002 and 200425. Four countries26 more than doubled their financing. Although two countries27 reduced the percentage of their ODA being spent on SRH from 2002 to 2004, three28 more than doubled this percentage. In 2004, the Netherlands provided more than 10% of its ODA and more than US$25 per person on SRH activities in developing countries. The Netherlands was also the largest EU contributor to selected international organisations with a focus on SRH and/or HIV/AIDS in 2003. In 2005, the UK was the largest contributor. 25 Although as previously noted and shown in Figure 4, the majority of this increase is for responses to HIV and AIDS 26 France, the Netherlands, Sweden and the UK 27 Finland and Germany 28 The Netherlands, Sweden and the UK Overall 2000-2005 50% 31% 19% 2005 39% 43% 18% Bilaterals Multilaterals Social Marketing Organisations/NGOs 16 17 Table 4: Support for Sexual and Reproductive Health in Developing Countries: Summary Financial Data for Selected European Donors – focus countries of Countdown 2015 Europe Total funding for SRH (US$m) % of ODA on SRH Funding for SRH per capita (US$) % of funds29 from EU countries30 to international organisations for SRH and/or HIV and AIDS 31 SRH funding through RH orgs per capita (US$) 2002 2004 2002 2004 2004 2003 2005 2004 Denmark 70 90 4.0 4.4 18 7 7 12 Finland 20 27 5.3 4.2 5 3 3 5 France 85 206 1.5 2.4 3 9 N/A 3 Germany 105 142 2.0 1.9 2 8 13 0.7 Netherlands 160 442 4.9 10.5 27 23 17 13 Sweden 60 197 3.1 7.2 22 7 15 16 UK 160 661 3.4 8.4 11 12 18 2 EC 180 159 2.8 1.8 N/A N/A N/A N/A Data Sources: UNFPA, 2005b and Euromapping Project 2007 Grading donor countries on their performance on SRH financing32 and policies33 (Leahy, 2007) shows another perspective. Current grades and historic grades, from 2004, are shown in Table 5. More details of scores for selected European donors are shown in Table 6. In general, the focus countries of Countdown 2015 Europe are among the better performing donors relating to sexual and reproductive health in developing countries. Among them are some strong performers, such as Denmark, the Netherlands, Sweden and, more recently, the UK. Others, such as France are improving. Germany has provided strong support to the provision of family planning supplies (see Figure 4). In general, countries have appropriate policies. Some examples of these are featured in Box 2. Some areas for improvement are: x Finland and the UK could increase their proportion of GNI provided as ODA x France and Germany could increase their proportion of GNI provided as ODA and the proportion of their ODA spent on SRH 29 In 2003, this was US$781m and in 2005 US$1,600m 30 And Switzerland and Norway 31 UNFPA, IPPF, UNIFEM, the Global Fund, UNAIDS and IPM 32 Using three scores of up to 20 each for % of GNI provided as ODA; % of ODA spent on SRH activities and degree to which donor has met its ‘fair share’ of ICPD commitments 33 Using an eight-point score in five policy areas – reproductive health; gender; existence of policy restrictions; support to UNFPA/IPPF and degree of tied aid Table 6: SRH Financing and Policy Scores: Current Detailed Scores for Focus Countries (see Leahy, 2007) 34 Financial Scores (m ax 20) Policy Scores (m ax 8) Country Current Grade 2004 Grade Total Score ODA as % of GNI SRH spend as % of ODA ICPD ‘fair share’ perform ance Reproductive Health Gender Policy Restrictions Support to UNFPA/ IPPF Use of untied aid Denm ark A A 93 18 *15 *15 8 8 8 8 7 Finland B A 79 7 18 18 4 8 8 8 7 France B C 63 8 6 17 4 8 8 4 8 Germ any B B 68 6 8 15 8 8 8 8 7 Netherlands A A 95 16 20 20 8 8 8 8 7 Sweden A A 95 16 19 20 8 8 8 8 8 UK A B 87 7 20 20 8 8 8 8 8 D ata S ource: L e ahy, 2007 w ith correction, pe rsonal correspondence S ex& S am fun d Scores assigned to countries on a scale of "A" to "F" (or full m arks of 100% to Failure) according to their perform ance as donors, based on the following indicators: x The generosity of each donor’s overall developm ent aid program in relation to the size of that country’s econom y; x The proportion of developm ent assistance funds allocated to reproductive health and population program s; x The distance each donor has to go to reach its "fair share" of the ICPD spending goal for 2005 from 2002 spending levels; and x The extent to which a country’s policies foster the m axim um level of im pact in addressing the goals of the ICPD Program m e of Action based on their official reproductive health and population policies, gender policies, percentage of "tied" aid, and contributions to key United Nations and non- governm ental organizations 34 Colour coding is based on the sam e as for grading – dark green for A (>80% ); light green for B (60-80% ); am ber for C (40-60% ) and red for D (<40% ) 18 Table 5: SRH Financing and Policy Scores: Current and 2004 (see Leahy, 2007) (Focus countries of Countdown 2015 Europe underlined and bold) A Grade B Grade C Grade D Grade 2004 2004 2004 2004 Denmark A Australia C Spain D Austria D Luxembourg A Belgium B Portugal D Greece - Netherlands A Canada B USA C Italy D Norway A Finland A Sweden A France B UK B Germany B Ireland C Japan B New Zealand B Switzerland B Data Source: Leahy, 2007 In relation to funding contraceptive and condom supplies, donors provided US$213m in 2005, of which 39% was provided directly by bilateral donors (see Figure 5, p15). The largest part of this (80%) was provided by the US. Significant European donors funding contraceptives and condoms bilaterally were Germany (16%) and the UK (4%) (UNFPA, 2005d). Other European donors funded contraceptive and condom supplies through their funding of UNFPA35, which accounted for 43% of all such funding in 2005 (see Table 8). The European Union and European Commission – Actions and Financing This section focuses mainly on the European Commission and its actions and financing for SRH activities in developing countries. However, it starts with a brief review of the contribution of the European Union and its member states as a whole. The European Union’s development policy, e.g. as stated in the European Consensus (Council of the EU, 2005), the Joint EU-Africa Strategy36 (Europa, 2007 and the Cotonou Agreement (ACP and the European Community, 2000 and 2005), includes strong commitments to the ICPD Programme of Action. The European Parliament has been active, e.g. through its Development Committee, in urging the Commission to focus more on poverty in its aid plans, including on health and education sectors. There have also been initiatives within the European Parliament to ensure that budget reports and instruments contain specific reference to reproductive health but unfortunately the Parliament rejected proposals to earmark the increase in funding for SRH for the 2008 budget In May 2007, the European Union proposed a voluntary code of conduct on complementarity and division of labour in development policy with the intention of making aid more effective as envisaged by the Paris Declaration. However, there is a risk that certain parts of this code, e.g. limiting the involvement of bilateral agencies to three sectors in-country could be taken by some donors to justify their non-engagement with issues of reproductive health or by others to justify their withdrawal from this sector (Council of the EU, 2007). According to UNFPA figures (UNFPA, 2005b), just over one third (38%) of the expected funds for SRH activities under the ICPD Programme of Action for 2006 were expected to come from EU member states. This proportion was similar for family planning programmes (38%) and responses to HIV and AIDS (36%). It was much higher for basic reproductive health programmes (57%) and very much lower for research (3%). These figures also reflect the funding priorities and practice of other major funders of SRH activities, particularly the US (see Figure 6). 35 And to a lesser extent through funding of NGOs, such as IPPF 36 Due to be adopted at the second EU-Africa Summit scheduled to be held in Lisbon in December 2007 19 Figure 6: Share of Different Types of SRH Funding: EU, US and Other Donors: 2006 Data Source: UNFPA, 2005b Applying a set of financing and policy scores (Leahy, 2007; see Table 5, p17) show the diversity of performance among EU states. Five (Denmark, Luxembourg, Netherlands, Sweden and the UK) of the six37 best performing donors are EU member states, but so are the three poorest performers (Austria, Greece and Italy). From 1994 to 2001 (covering the Financial Perspectives 1993-1999 and 2000-2006), the European Commission provided � 655.4m as population assistance (Particip GmbH, 2004). Of this, 43% was for responses to HIV and AIDS, 27% for reproductive health, 13% for family planning, 10% for safe motherhood and 6% for population policy and management. Figures in Table 4, show that between 2002 and 2004, the European Commission reduced both funding for SRH activities and the proportion of ODA spent on SRH interventions. There are concerns that this reduced level of funding indicates a reduced policy focus on SRH by the European Commission (see Box 3). Advocates consider the European Commission to be inconsistent in its support to SRH38. The total amount of money for SRH during the last financial perspective (2003-200639) was � 70.1 m. The EC has pledged that it will make the same amount of money available for the period 2007-2013, although the current Financial Perspective spans 7 years while the money allocated in the previous Financial Perspective to SRH only covered three years. Figures for 2006 show that the proportion of the EC’s SRH funding of HIV and AIDS had increased significantly to over 90%. 2006 marks the end of the 2000-2006 financial perspectives and therefore the funds leftover must be spent. It is worth noting that the increase is in great part due to the fact that for accounting purposes, the EC must spend the money rather than political will to increase funding. (see Figure 4). In addition, in 2007, the European Commission’s entire health envelope within ‘Investing in People’ was allocated to the Global Fund (Action for Global Health, 2007). One of the underlying principles of the Global Fund is to make available and leverage additional financial resources to combat HIV/AIDS, tuberculosis and malaria. Donor contributions to the Global Fund should be in addition to, not a replacement of, existing funding. Using the entire available health budget to meet the Commission’s commitments to the Global Fund is not in keeping with that principle. 37 The other is Norway 38 personal correspondence MSI 39 The SRH budget line was only introduced in 2003 – following a report on SRH by the former President of the EPWG. 37% 61% 2% 3% 95% 2% 36% 59% 5% 57% 9% 34% European Union Member States United States Other Basic Reproductive Health Services Family Planning HIV and AIDS Research 20 Box 2: Has the European Commission Reduced its Policy Focus on SRH? Evidence of ongoing policy commitment includes strong reference to SRH in recent EC policy documents, e.g. on gender equality and women empowerment (EC, 2007). Evidence of reduced policy commitment includes: x Prioritisation by Commissioner Louis Michel of issues of trade, infrastructure and regional integration x The absence of a specific budget line for sexual and reproductive health in the new thematic funding programme ‘Investing in People’ x The absence of a focus on reproductive health in the Commission’s country programmes. Of the Commission’s 106 country strategy papers, 38 (36%) refer to support for health, 13 (12%) to HIV/AIDS and 42 (40%) to gender (Euromapping Project, 2007). Funding to International Organisations From 2003 to 2005, the countries of the European Union increased their funding to a number of organisations who have a focus on or benefit to reproductive health from US$871m to US$1,600m. Organisations40 received an increase in funding from EU countries of between 25-70%. (see Table 7; Euromapping Project, 2007). The seven donor countries and the European Commission that are the focus of Countdown 2015 are important funders of organisations working on reproductive health. In 2006, they provided between 38%-63% of these organisations’ funds (see Table 8). Table 7: Funding to Organisations Working on Reproductive Health from Countries of the EU: 2003 and 2005 (US$m) 2003 2005 % increase Global Fund to Fight AIDS, TB and Malaria 385 656 70% United Nations Population Fund (UNFPA) 235 293 25% Joint United Nations Programme on HIV and AIDS (UNAIDS) 89 130 46% International Planned Parenthood Federation (IPPF) 42 47 11.9% United Nations Development Fund for Women (UNIFEM) 23 35 52% International Partnership for Microbicides (IPM) 7 11 57% Data Sources: Euromapping Project, 2007, IPPF (individual correspondence) UNFPA’s Global Programme to Enhance Reproductive Health Commodity Security provides a structure for moving beyond ad hoc responses to stockouts towards more predictable, planned and sustainable country-driven approaches for securing essential supplies and ensuring their use. Budgeted at US$150m per year, it provides three funding streams to build capacity, enhance systems and avoid stockouts (UNFPA, 2006a). To date, UNFPA has US$39m available for this fund. Sources of these funds are shown in Table 9. 40 Euromapping reviewed funding trends by considering total grants to these organisations posing risk of overestimation as most donors would attribute differential percentages of grants to these agencies as contributing towards SRH. 21 Table 8: Funding Trends to Organisations Working on Reproductive Health from Focus Donors (US$m – all figures 2006) Global Fund41 UNFPA42 UNAIDS43 IPPF44 UNIFEM45 Rank Amount Rank46 Amount Denmark 24 6 31 6 8 8.4 1.9 Finland 4 8 17 10 9 0.9 1.5 France 293 16 2 14 3 0.0 0.0 Germany 88 7 20 13 2 4.6 1.5 Netherlands 77 1 75 2 38 5.4 0.2 Sweden 82 2 55 5 34 15.6 11.1 UK 120 4 38 4 29 14.4 8.0 EC 117 N/A N/A 22 0.4 3.6 0.0 % of total funding 40% 63% 53% 49%47 38% Data Source: Euromapping Project, 2007 Table 9: Sources of Funds for Global Programme to Enhance Reproductive Health Commodity Security (US$m)(Focus countries of Countdown 2015 Europe underlined and bold) Donor Amount European Commission 10.6 UK 9.8 Netherlands 6.0 Canada 4.0 Sweden 3.7 Finland 1.9 Spain 1.5 Ireland 0.7 UN Foundation 0.4 Data Source: UNFPA, 2006a OPTIONS FOR MAKING PROGRESS TOWARDS GREATER INVESTMENT IN REPRODUCTIVE HEALTH SUPPLIES Financial Targets International Parliamentary Conferences on the implementation of the ICPD Programme of Action (Ottawa, 2002; Strasbourg, 2004; Bangkok,2006 – UNFPA, 2007b) and European and African Parliamentarian conferences in advance of G8 summits (Edinburgh, 2005; Berlin, 2007) have called on donor countries to allocate at least 10 per cent of development assistance and national development budgets to reproductive health. Only the Netherlands had met this target as of 2004, although both Sweden and the UK had made substantial progress towards it (see Figure 7). 41 From Global Fund, 2007a 42 From UNFPA, 2007a 43 From UNAIDS, 2007a 44 From IPPF, 2007 45 From UNIFEM, 2007 46 This ranking is for financial contributions to UNAIDS for the period 1995-2006 47 The seven countries featured provided 64% of all funds from individual donor countries to IPPF 22 Figure 7: SRH Funding from Selected European Countries and the EC for 2002 and 200448 0 2 4 6 8 10 12 De nm ark Fin lan d Fra nce Ge rm any Ne the rlan ds Sw ede n UK EC % o f O DA o n SR H Target level 20 02 20 04 20 02 20 04 20 02 20 04 20 02 20 04 20 02 20 04 20 02 20 04 20 02 20 04 20 02 20 04 Data Sources: UNFPA, 2005b and Euromapping Project 2007 However, levels for this target depend on the amount of funding provided as ODA by different countries. This amount varies widely, with only five countries currently meeting the target of providing 0.7% of GNI as ODA (Table 6 p19). It is therefore essential for countries to meet this target also. Both targets could be incorporated into one, namely that countries should provide 0.07% of their GNI as ODA for SRH programmes. Also, there have been calls for donors to spend 15% of their ODA and 0.1% of their GNI on health (Action for Global Health, 2007). Assuming that SRH spending is a sub-set of health spending, this would require two thirds of health spending to be focused on sexual and reproductive health49. Parliamentarians from G8, European and African countries have consistently called50 for 10% of ODA to spent on SRH Mechanisms for Enhancing Expenditure This section is divided into two parts. The first examines issues relating to financing sexual and reproductive health at country level. The second explores issues related to donor financing. A great deal has been written recently about new approaches to health financing (e.g. Braine, 2006), which form part of an overall process of health sector reform, and their effect on sexual and reproductive health services (Dmytraczenko et al., 2003). This section will briefly consider three elements of in-country financing of sexual and reproductive health – resource mobilisation, resource pooling and purchasing (WHO, 2006). Sources of financial resources for sexual and reproductive health services include tax-based public funding, various types of insurance schemes, out-of-pocket financing and external aid51. In developing countries, the tax base is very small (WHO, 2006). National insurance schemes52 seldom reach national coverage and risk bringing benefits mainly to richer people, particularly men (WHO, 2006; Standing, 2002). Community insurance might be better but experience shows that inequities still exist because 48 Colour coding – red <4%; orange 4-10%; green >10% 49 Defined as including sexual and reproductive health rights, maternal and neonatal health and responses to HIV and AIDS 50 Edinburgh Declaration (2005), Berlin Appeal (2007) 51 Considered later in this section 52 Usually employment-based with or without public funding for those not in employment 23 premiums are high and exemption systems function poorly (McPake, undated). Schemes may not cover some sensitive services, e.g. family planning or some groups, e.g. unmarried adolescents (WHO, 2006). Out of pocket expenditure remains an important means of financing sexual and reproductive health services, accounting for more than 50% of financing in some countries, e.g. Bangladesh, Peru, Thailand and Uganda (McPake, undated). Insurance schemes and newer aid instruments53 are ways of pooling resources for health services, including those for reproductive health (WHO, 2006). Pooled approaches, in principle, should allow resources to be allocated more cost-effectively to areas where they will make maximum public health benefit. However, experience shows that there are often problems with such prioritisation in practice with resources focused on issues of lower public health priority and disproportionately benefiting richer people and urban areas (McPake, undated). Pooling of resources also creates challenges in tracking how they are expended on particular areas of health, e.g. SRH (see p26). Discussions of purchasing of SRH services focus largely on the role of the private sector. This sector is heterogeneous, consisting of both for-profit and not-for-profit providers (Standing, 2002). This sector is currently providing a significant proportion of SRH services in many countries54 and is the main recipient of out-of-pocket payments (McPake, undated). Some consider that more services could be provided through this sector, e.g. through social marketing. Non-profit providers may have a particular role in providing services in underserved areas (McPake, undated). However, concerns about increasing use of private providers include increasing inequities (WHO, 2006), poor quality of services, increasing inefficiencies and undermining the coherence and sustainability of the health system (Doherty, 2005). Much of the discussion about donor financing, in general, and for SRH and HIV and AIDS in particular, has focused on the issue of aid effectiveness. Aid, which has been unpredictable in timing and magnitude, has had major negative impact on the delivery of reproductive health supplies (Reproductive Health Supplies Coalition, 2006). The Paris Declaration on Aid Effectiveness provides five principles for addressing this situation, namely alignment, harmonisation, ownership, results and mutual accountability. Many donor countries are now trying to deliver their aid in ways, which are consistent with those principles. This is seen, for example, in the recent establishment of an International Health Partnership and in the focus on country-led approaches and newer aid instruments, such as general and sectoral budget support. This shift has considerable implications for the funding of SRH (Standing, 2002, Vogel, 2006) and raises important questions for donors: x To what extent should funding for SRH be provided through bilateral or multilateral channels? Donors currently answer this question very differently (see Figure 8, p26) x How effective are Global Health Partnerships, such as the Global Fund to Fight AIDS, TB and Malaria in funding sexual and reproductive health (see p27). Concerns have been raised that increased levels of financing for HIV and AIDS may be negatively affecting financing for other SRH elements, e.g. family planning (see p14). This has been part of the rationale for calls for stronger linkages between reproductive health programmes and responses to HIV and AIDS (Druce et al., 2006). x To what extent will new mechanisms for financing drug purchasing, e.g. UNITAID55 have positive benefits for reproductive health supplies? Are specific mechanisms needed for reproductive health supplies, such as minimum volume or pledge guarantees56 (Reproductive Health Supplies Coalition, 2006)? x To what extent are new systems/initiatives needed, such as UNFPA’s Global Programme for Enhancing Reproductive Health Commodity Security and The RHInterchange (Supply Initiative, undated, b)? 53 Such as sectoral and general budget support (see p23) 54 For example, Nicaragua – where social insurance was estimated to cover only 13% of the population (Carrazana, undated) 55See http://www.unitaid.eu/ 56Pledge guarantee is a mechanism to advance money to a party based on projected financing flows from donors. Minimum volume guarantee is given to manufacturers to allow larger-scale production and reduction of unit costs. 24 x What mechanisms are needed to improve donor coordination on reproductive health supplies? How will the International Health Partnership address this? There are a number of implications of this financing environment for sexual and reproductive health. First, it makes monitoring more complex. It is more difficult to track spending on sexual and reproductive health, in general, and RH supplies, in particular, when funding is provided as general or sectoral budget support rather than to specific SRH projects. Mechanisms for doing this include public expenditure reviews, national health accounts and women’s budgets. Each has its advantages and disadvantages (Standing, 2002). Second, advocacy on SRH issues is more complex and requires an understanding of the new aid architecture (Vogel, 2006). A shift to country-led approaches means that more advocacy/policy dialogue is needed at country level, e.g. for the inclusion of sexual and reproductive health in Poverty Reduction Strategies (PRSs) and Medium Term Expenditure Frameworks (MTEFs)57. This is a key focus of UNFPA’s Global Programme for Enhancing Reproductive Health Commodity Security. Figure 8: The Extent to Which Selected Donors Fund SRH Services through Bilateral or Multilateral Channels58 Finland UK France Germany Denmark ECNetherlands Sweden Data Sources: UNFPA, 2005b and Euromapping Project 2007 Mostly Bilateral Mostly Multilateral The Potential of the International Health Partnership A new international health partnership was launched recently by the UK,59 which aims to improve coordination among donors, focus on strengthening health systems as a whole and develop and support countries’ own health plans (DFID, 2007). The ‘first wave’ of countries in the partnership are Burundi, Cambodia, Ethiopia, Kenya, Mozambique, Nepal and Zambia. The International Health Partnership could have benefits for sexual and reproductive health as potential big wins are refocusing health aid from treatment of specific disease to the development of health systems as a whole, reversing the tendency to fund certain diseases and providing a framework for harmonisation and alignment which will greatly reduce the transaction costs and distortions facing recipient countries. However, to have maximum benefit, it will need to: x Include all major donors, e.g. the US and Japan, and be expanded beyond the ‘first wave’ of countries x Demonstrate actual achievements, in terms of implementing the principles of the Paris Declaration on Aid Effectiveness x Show that it is applicable in fragile states 57 And in donor instruments, such as Country Strategy Papers/Country Assistance Plans 58 Based on data presented in Table 4 59 Signatories to the IHP agreement include Canada, France, Germany, Italy, The Netherlands, Norway, Portugal, The European Commission, African Development Bank, UNAIDS, UNFPA, UNICEF, World Bank, WHO, GAVI Alliance, Global Fund to Fight AIDS, TB and Malaria and the Bill and Melinda Gates Foundation 25 x Leverage large reallocations of health spending (Maxwell, 2007) There is also need to see how it fits with other initiatives to improve aid effectiveness, such as the EU’s code of conduct on complementarity and division of labour, adopted in May 2007. It remains to be seen at country level, how the Ministry of Health, Ministry of Finance and other key stakeholders will ensure that intervention-specific plans, importantly the recently defined national plans for scaling up towards universal access to HIV and AIDS services, are complementary to national planning process to builds on, not replace, existing progress. Additionally the approach should be harmonized with the plans for RHCS but at present only Ethiopia is both a focus country of the IHP and the UNFPA Global Programme on RHCS. The Role of the Global Fund to Fight AIDS, TB and Malaria Box 3: Effects of Global Fund Financing on Reproductive Health in Ethiopia and Malawi A study showed that reproductive health players had not been actively involved in planning the proposal for the Global Fund and that activities financed by the Global Fund were not integrated with existing reproductive health and family planning services. Workload on staff had increased and there was shift of human resources towards activities financed by the Global Fund. Procurement and disbursement of pharmaceuticals had improved in Ethiopia but not in Malawi (Schott et al., 2005) To date, there has been very little emphasis on integration between SRH-HIV and AIDS in the Global Fund’s policy documents, guidelines, proposals, progress and financial reports (Dickenson, 2006). Studies have shown a lack of support to sexual and reproductive health services from the Global Fund (see Box 5). In a survey of 104 IPPF Member Associations, 18 reported that they were members of Country Coordinating Mechanisms (CCMs). Another 13 were involved in CCMs in some way. The main barrier to Member Association involvement in CCMs was lack of information. In some cases, there was misinformation, e.g. the belief that the Principal Recipient of Global Fund money cannot receive funds for its own activities. Over half (59%) of Member Associations had submitted a proposal for Global Fund monies and half of these had been successful but they reported long delays in receiving those funds (GTZ and IPPF, 2005). Global Fund financing might also impact SRH services indirectly through effects on the health system (UK Stop AIDS Campaign, 2007; PHRPlus, 2006). There is some evidence that the Global Fund has strengthened some health systems, e.g. through training and provision of equipment and infrastructures (Friends of Global Fight Against AIDS, TB and Malaria, 2007). The Global Fund’s guidelines for Round 7 (Global Fund, 2007b) contained a strong focus on health systems strengthening, for example, including the requirements to assess the national health system, to identify strategic actions to strengthen health systems and to explain any possible adverse effects on health systems of planned actions. This has emboldened organisations to call for proposals to include ambitious human resource requirements in their proposals, as Malawi did in Round 5 (Asia Pacific Action Alliance, 2007). In consultation with the Global Fund, in advance of Round 7, it was confirmed that proposals that establish linkages with SRH systems are acceptable to the Global Fund provided that a positive outcome can be demonstrated for one of the three diseases. Acceptable integrated services include, but are not limited to, financing and provision of family planning services and reproductive health supplies (Interact Worldwide, 2006). However, the Global Fund’s guidelines have not made any specific mention of reproductive health services. NGOs have produced guidelines on how sexual and reproductive health could be included in proposals to the Global Fund (Global AIDS Alliance et al., 2007a), including integrated treatment of STIs, integrated VCT, PMTCT, provision of ART, adolescent STI and HIV prevention programmes, integrated SRH services for vulnerable populations, and activities to combat gender-based violence. They also produced an Advocacy Action Plan (Global AIDS Alliance et al., 2007b) to provide countries with options on influencing Global Fund governance at national level and working on institutional reform at the Board and Secretariat. Currently there is a call for the Global Fund to be explicit in its support for SRH-HIV and AIDS integration, beginning by approving a Round 8 Call for Proposals that outlines the funding opportunities for SRH programming and reproductive health supplies. 26 Through this report’s review of available evidence of donor support to improve sexual and reproductive health and enhance the availability of reproductive health supplies it is clear that the needs of the poor have not been compelling enough yet. Countdown 2015 Europe is committed to improve transparency in ODA for SRH and RHS and will continue to influence policy makers in each of our focus countries of the need to explicitly report multilateral and bilateral support to achieve universal access to reproductive health. REVIEW OF RECOMMENDATIONS FULL FUNDING - Countdown 2015 Europe calls on donor governments to take urgent action to provide one third of these resources and meet targets of US$9.9b in 2010 and US$11.9b in 2015. INCREASE ODA – Countdown 2015 Europe calls on donor governments to provide 0.7% of their Gross National Income as ODA and 10% of ODA to go to sexual and reproductive health. ADDITIONALITY – Countdown 2015 Europe urges donors to ensure that funds for HIV and AIDS are not being provided at the expense of addressing universal access to reproductive health. ENSURE COMMODITY SECURITY –Countdown 2015 calls upon donor governments to ensure prioritisation through bilateral and multilateral efforts. SRH-HIV/AIDS INTEGRATION – Countdown 2015 Europe calls on European donors to increase effective use of resources through appropriately integrated and linked responses to sexual and reproductive health, HIV and AIDS. HEALTH SYSTEMS AND HEALTH WORKFORCE –Countdown 2015 Europe calls on donor governments to ensure that aid instruments provide long-term, sustainable investment in health systems strengthening, particularly for significant investment in human resources for reproductive health. EDUCATION SECTOR RESPONSE TO SRH –. Countdown 2015 Europe calls on donors to fund comprehensive evidence–based sexuality education to help educate the public on SRH and create demand for the provision of RH supplies. NATIONAL PRIORITY SETTING – Countdown 2015 Europe calls on donors to support the Paris Declaration on Aid Effectiveness principles, to engage in policy dialogue with national governments to ensure that the importance of reproductive health supplies is recognised and provide technical assistance to build capacity. EUROPEAN COMMISSION – Countdown 2015 Europe calls on the European Commission to enact commitments of the European Consensus on Development and urgently ensure that funds for reproductive health are prioritised in country and thematic programmes. GLOBAL FUND – Countdown 2015 Europe calls on the Global Fund to be explicit in its support for SRH-HIV/AIDS integration, beginning by approving a Round 8 Call for Proposals that outlines the funding opportunities for SRH programming and reproductive health supplies. 27 28 ABBREVIATIONS ACP Africa, Caribbean and the Pacific AIDS Acquired Immunodeficiency Syndrome ART Antiretroviral Therapy CCM Country Coordinating Mechanism DAC Development Assistance Committee DFID Department For International Development (UK) DKT Social Marketing Organisation DSW Deutsche Stiftung Weltbevölkerung E&P Equilibres et Population EC European Commission EPF European Parliamentary Forum EU European Union GAVI The GAVI Alliance formerly Global Alliance for Vaccines and Immunisation GNI Gross National Income previously Gross National Product (GNP) GTZ German Development Agency HIV Human Immunodeficiency Virus ICPD International Conference on Population and Development IPM International Partnership on Microbicides IPPF EN International Planned Parenthood Federation (European Network) MDG Millennium Development Goals MSI Marie Stopes International MTEF Medium Term Expenditure Framework NGO Non Government Organisation ODA Official Development Assistance PAI Population Action International PATH Program for Appropriate Technology in Health PMTCT Prevention of Mother to Child Transmission PRS Poverty Reduction Strategy PSI Population Services International RFSU Swedish Association for Sexuality Education RH Reproductive Health RHCS Reproductive Health Commodity Security SRH Sexual and Reproductive Health STI Sexually Transmitted Infection SWAP Sector-Wide Approach SWEF Systemwide Effects of the Fund TB Tuberculosis UK United Kingdom UN United Nations UNAIDS Joint United Nations Programme on HIV and AIDS UNF United Nations Foundation UNFPA United Nations Population Fund UNICEF United Nations Children’s Fund UNIFEM United Nations Development Fund for Women US United States of America USAID United States Agency for International Development US$ United States Dollar VCT Voluntary Counselling and Testing WHO World Health Organisation WPF World Population Foundation REFERENCES ACP and the European Community (2000) Partnership Agreement between the Members of the African, Caribbean and Pacific Group of States of the One Part and the European Community and its Member States of the Other Part ACP and the European Community (2005) Agreement Amending the Partnership Agreement between the Members of the African, Caribbean and Pacific Group of States of the One Part and the European Community and its Member States of the Other Part Action for Global Health (2007) Health Warning: Why Europe Must Act Now to Rescue the Health MDGs Africa Union (2006) Special Session of the Conference of African Union Ministers of Health: Universal Access to Comprehensive Sexual and Reproductive Health in Africa Available on http://www.africa- union.org/root/au/Conferences/Past/2006/September/SA/ Maputo/CAMH2.htm Asia Pacific Action Alliance on Human Resource for Health (2007) Call to Action: Health Systems Strengthening through the Global Fund Banteyerga, H., Kidanu, A. and Stillman, K. 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(2006) The Changing Face of Foreign Assistance: New Funding Paradigms Offer a Challenge and an Opportunity for Family Planning Research Commentary, September 2006, Volume 1, Issue 8 WHO (2005) World Health Report 2005: Make Every Mother and Child Count WHO (2006) Financing Sexual and Reproductive Health- Care Services in Policy Brief 1, produced by WHO’s Reproductive Health and Research Team WHO, UNFPA and PATH (2006) Essential Medicines for Reproductive Health: Guiding Principles for their Inclusion on National Medicine Lists Available from http://www.who.int/reproductive- health/publications/essential_medicines/guidingprinciples. html WHO (2007) The Global Fund’s Strategic Approach to Health Systems Strengthening: A Short History Prepared for a meeting in July 2007 World Bank (2002) Maternal Health Available on http://wbln0018.worldbank.org/HDNet/hddocs.nsf/vtlw/AF B091BD50E294E285256D5E0065504D?OpenDocument 32 ACKNOWLEDGEMENTS Author: Roger Drew Editor: M. Felicity Daly, Senior Policy and Advocacy Manager, Interact Worldwide The author thanks the following who were consulted for this report: Stan Bernstien, Senior Policy Advisor, Technical Support Division, UNFPA Steve Kinzett, Technical Officer, Reproductive Health Supplies Coalition Benedict Light, Technical Adviser on Reproductive Health Commodity Security, UNFPA Abigail Holman, for initial research Reviewers: Renate Bähr (DSW), Yvonne Bogaarts (WPF), Jacqueline Bryld (Sex&Samfund), Vicky Claeys (IPPFEN), An Huybrechts (IPPFEN), Sophie Peresson (MSI), Julia Schalk (RFSU), Hilkka Vuorenmaa (Vaestoliitto) 325 Highgate Studios | 53-79 Highgate Road | London NW5 1TL T: +44 (0)20 7241 8500 F: +44 (0)20 7267 6788 E: info@interactworldwide.org www.interactworldwide.org Registered Charity No. 1001698 Company No. 2567545 << /ASCII85EncodePages false /AllowTransparency false /AutoPositionEPSFiles true /AutoRotatePages /None /Binding /Left /CalGrayProfile (Dot Gain 20%) /CalRGBProfile (sRGB IEC61966-2.1) /CalCMYKProfile (U.S. Web Coated \050SWOP\051 v2) /sRGBProfile (sRGB IEC61966-2.1) /CannotEmbedFontPolicy /Warning /CompatibilityLevel 1.6 /CompressObjects /Off /CompressPages false /ConvertImagesToIndexed true /PassThroughJPEGImages true /CreateJobTicket false /DefaultRenderingIntent /Default /DetectBlends true /DetectCurves 0.0000 /ColorConversionStrategy /LeaveColorUnchanged /DoThumbnails false /EmbedAllFonts true /EmbedOpenType false /ParseICCProfilesInComments true /EmbedJobOptions true /DSCReportingLevel 0 /EmitDSCWarnings false /EndPage -1 /ImageMemory 1048576 /LockDistillerParams false /MaxSubsetPct 100 /Optimize false /OPM 1 /ParseDSCComments true /ParseDSCCommentsForDocInfo true /PreserveCopyPage true /PreserveDICMYKValues true /PreserveEPSInfo true /PreserveFlatness false /PreserveHalftoneInfo false /PreserveOPIComments false /PreserveOverprintSettings true /StartPage 1 /SubsetFonts true /TransferFunctionInfo /Apply /UCRandBGInfo /Preserve /UsePrologue false /ColorSettingsFile (None) /AlwaysEmbed [ true ] /NeverEmbed [ true ] /AntiAliasColorImages false /CropColorImages false /ColorImageMinResolution 300 /ColorImageMinResolutionPolicy /OK /DownsampleColorImages false /ColorImageDownsampleType /Average /ColorImageResolution 400 /ColorImageDepth -1 /ColorImageMinDownsampleDepth 1 /ColorImageDownsampleThreshold 1.50000 /EncodeColorImages false /ColorImageFilter /None /AutoFilterColorImages false /ColorImageAutoFilterStrategy /JPEG /ColorACSImageDict << /QFactor 0.15 /HSamples [1 1 1 1] /VSamples [1 1 1 1] >> /ColorImageDict << /QFactor 0.15 /HSamples [1 1 1 1] /VSamples [1 1 1 1] >> /JPEG2000ColorACSImageDict << /TileWidth 256 /TileHeight 256 /Quality 30 >> /JPEG2000ColorImageDict << /TileWidth 256 /TileHeight 256 /Quality 30 >> /AntiAliasGrayImages false /CropGrayImages false /GrayImageMinResolution 300 /GrayImageMinResolutionPolicy /OK /DownsampleGrayImages false /GrayImageDownsampleType /Average /GrayImageResolution 400 /GrayImageDepth -1 /GrayImageMinDownsampleDepth 2 /GrayImageDownsampleThreshold 1.50000 /EncodeGrayImages false /GrayImageFilter /None /AutoFilterGrayImages true /GrayImageAutoFilterStrategy /JPEG /GrayACSImageDict << /QFactor 0.15 /HSamples [1 1 1 1] /VSamples [1 1 1 1] >> /GrayImageDict << /QFactor 0.15 /HSamples [1 1 1 1] /VSamples [1 1 1 1] >> /JPEG2000GrayACSImageDict << /TileWidth 256 /TileHeight 256 /Quality 30 >> /JPEG2000GrayImageDict << /TileWidth 256 /TileHeight 256 /Quality 30 >> /AntiAliasMonoImages false /CropMonoImages false /MonoImageMinResolution 1200 /MonoImageMinResolutionPolicy /OK /DownsampleMonoImages false /MonoImageDownsampleType /Average /MonoImageResolution 1200 /MonoImageDepth -1 /MonoImageDownsampleThreshold 1.50000 /EncodeMonoImages false /MonoImageFilter /None /MonoImageDict << /K -1 >> /AllowPSXObjects false /CheckCompliance [ /None ] /PDFX1aCheck false /PDFX3Check false /PDFXCompliantPDFOnly false /PDFXNoTrimBoxError true /PDFXTrimBoxToMediaBoxOffset [ 0.00000 0.00000 0.00000 0.00000 ] /PDFXSetBleedBoxToMediaBox true /PDFXBleedBoxToTrimBoxOffset [ 0.00000 0.00000 0.00000 0.00000 ] /PDFXOutputIntentProfile (None) /PDFXOutputConditionIdentifier (CGATS TR 001) /PDFXOutputCondition () /PDFXRegistryName (http://www.color.org) /PDFXTrapped /False /CreateJDFFile false /Description << /ENU ([Based on 'trueflow 4 hi res'] Use these settings to create Adobe PDF documents for quality printing on desktop printers and proofers. 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