Stewardship for FP2020 Goals: The Role of Parliamentarians

Publication date: 2014

HEALTH POL ICY P R O J E C T STEWARDSHIP FOR FP2020 GOALS THE ROLE OF PARLIAMENTARIANS August 2014 Introduction Ministries of health are largely responsible for achieving the commitments that their national governments have made as part of the FP2020 initiative, which aims to enable 120 million more women and girls to use contraceptives by 2020. However, in their efforts to achieve FP2020 commitments, ministries of health often face significant funding constraints. The ministries submit budget requests for family planning (FP) programs, but if they do not receive the requested allocations, they often lack the administrative authority and standing to demand the requested funds. Elected officials who hold political authority, particularly members of Parliament (MPs), are uniquely positioned to support Ministry of Health (MOH) stewardship of family planning by promoting and approving funding for FP policies and programs. Foremost, they support the MOH by passing budgets that provide public funding to the health sector. In addition, parliamentarians are empowered to call hearings, mandating officials to provide information and justification for their actions and policies. Brief Elizabeth Leahy Madsen Health Policy Project, Futures Group Brief Series: Supporting MOH Stewardship for FP2020 As stewards, ministries of health are responsible for “the careful and responsible management of the well- being of the population” (WHO, 2000). However, the ministries’ ability to meet FP2020 goals depends on the strength of their stewardship functions, including overseeing the policy and regulatory environment, building partnerships with and generating support from other actors and across sectors, and fostering policy implementation. This series of three briefs provides guidance on the key roles of both ministries of health and parliamentarians in supporting stewardship for FP2020. The briefs address ƒ The role of the MOH in strengthening family planning policy implementation ƒ The role of parliamentarians in securing funding for FP ƒ The role of the MOH in strengthening linkages with the private sector to achieve FP2020 goals 2 August 2014 Parliamentarians can also raise the political profile of FP by serving as conduits between the MOH and the populations they serve. MPs are the targets of advocacy by civil society organizations (CSOs), which provide them with information about the problems affecting their constituents. In turn, MPs can use this information when advocating to their fellow government officials. MPs’ position and authority afford them direct, high-level access to other policymakers. When politicians champion a cause, they can amplify the message and increase the likelihood of achieving the goal. The USAID-funded Health Policy Project, including its partner, Partners in Population and Development Africa Regional Office (PPD ARO), has been working to build capacity for FP policy advocacy in several African countries. Drawing from these experiences, this brief describes four skills that MPs can develop and strengthen to more effectively lobby for, demand, and secure policy change and increased funding for FP: 1. Identify decisionmakers who will support FP 2. Use evidence to build support for a policy change 3. Map barriers to the achievement of policy goals 4. Design an advocacy strategy Skill: Identify Decisionmakers Who Will Support FP MPs have greater access to policymakers than civil society and, often, MOH officials; they can secure meetings with ministers of finance and other high-level officials. Compared to MOH officials, MPs’ political position as arbiters of the national budget enables them to communicate more quickly and on a more equal footing with the Ministry of Finance (MOF). They can also generate significant media attention and rally members of the public to raise the profile of an issue among their policymaking peers. While MPs have fairly broad access to decisionmakers, they must reach out strategically to those who can influence relevant policies or are likely to become allies and provide high-visibility support. To be able to identify which decisionmakers to target, MPs must develop their skills in assessing and analyzing responsibilities. Generally, beyond Parliament, officials at the MOF and other agencies are responsible for budget allocations, while the authority to make policy and regulatory changes as part of FP2020 commitments may rest within the MOH. MPs and MOH officials can work together to identify political and funding bodies that have direct oversight roles or other influence on FP issues. These may include the MOF and parliamentary committees on budget, health, social affairs, and women and youth. Existing networks can be vital sources of support (e.g., country chapters of the Network of African Women Ministers and Parliamentarians). In many countries, decentralization has introduced new stakeholders for FP, with authority diffused among significantly more entities and leaders. Some newly empowered local leaders have used their unilateral power to implement policies that restrict rather than expand access to FP. In the Philippines, for example, the mayor of Manila issued a stringent executive order in 2000 that prohibited the public distribution of family planning supplies and contributed to a 77 percent drop in the contraceptive prevalence rate within four years (Lee et al., 2009). When local-level health officials must comply with such political demands, decentralization can lead to policies or practices that restrict couples’ FP options, in the absence of the review, debate, or oversight that Parliament or another national-level political body might have provided. However, when regional and local- level parliaments and councils are created as part of the decentralization process, they can provide forums to engage with CSOs and advocate on behalf of constituents who might not have access to policymakers at the national level, including women in need of contraception. Case Study: Identifying Target Decisionmakers in Ethiopia In 2012, a delegation of Ethiopian MPs from three parliamentary committees (Social; Budget and Finance; and Women, Children and Youth), each with oversight of issues related to FP, participated in a policy training by HPP and PPD ARO and made commitments to increase the national budget for reproductive health by 1 percent and for FP commodities by 3 percent within one year. The Federal Ministry of Health (FMOH) budget is submitted to and finalized by the Ministry of Finance and Economic Development (MOFED) before being presented to Parliament for approval, so the parliamentarians decided to focus their advocacy efforts on MOFED. They secured a meeting with MOFED officials, during which they made a case to increase the health budget channeled to FMOH. 3 Stewardship for FP2020 Goals Parliamentarians from the three committees followed up with a budget analysis meeting with FMOH and MOFED. The combined outreach efforts of MPs and FMOH staff led to a major increase in the funding request for fiscal year (FY) 2013–14, from US$194 million to US$247 million for the health budget and from US$56 million to US$150 million for the budget line for FP. The engagement of parliamentarians raised the visibility of FP and overall health funding among key decisionmakers, generating increased support within the influential MOFED. Building support within MOFED was a critical step toward success. One week later, the same MP presented a position paper on the floor of Parliament, with 540 other MPs in attendance. In both presentations, the MP described the situation of FP in Ethiopia in clear terms, supported by evidence from demographic and health indicators, and called on the government to increase the health budget so the country can meet the Millennium Development Goals. Her clear funding request, backed up by compelling and relevant data, raised the profile of the issue and broadened the base of support among MPs and other policymakers. Skill: Use Evidence to Build Support for a Policy Change Countries have made various types of FP2020 commitments, ranging from quantified budget increases to improvements in the FP policy and service environment. All types of commitments require a solid base of evidence to win support among decisionmakers, who may face competing demands for a limited amount of funding or feel unprepared to approve new guidelines given their limited specialized knowledge of FP. MPs, who understand the budgetary and legislative issues that fall within their authority, and MOH officials, who have access to evidence and monitoring data, can work together to translate commitments into concrete requests that are achievable within the bounds of a parliamentary session or fiscal year. The specific policy request can then be disseminated among a broader set of stakeholders who are positioned to consolidate support among key institutions and decisionmakers. Case Study: Building Support for a Funding Increase in Ethiopia Armed with evidence from demographic and health indicators, in January 2013 a group of MPs from three parliamentary committees created a strategy to disseminate this evidence and use it to demonstrate an existing need for FP. The MPs organized a panel discussion that was attended by more than 350 parliamentarians and about 125 other stakeholders (including representatives from FMOH, MOFED, and line ministries; health institutions, nongovernmental organizations (NGOs), and development partners; and service providers in public facilities). During this meeting, one of the MPs presented a paper on the need to increase the health budget and the budget for FP. Skill: Map Barriers to the Achievement of Policy Goals To effectively map barriers, MPs must develop an understanding of the policy, political, regulatory, funding, and other contexts that shape and can inhibit the achievement of FP2020 commitments. High-level officials may not have known of these barriers when the commitments were planned and announced. Similarly, MPs work across many sectors and may not be aware of specific barriers to improving access to or use of FP. The MOH and civil society can ensure that MPs are informed of key obstacles to achieving national goals and can plan how to overcome them. Case Study: Mapping Barriers in Malawi In Malawi, MPs mapped a critical barrier to improving FP when they learned that a year after the country’s new FP commodities budget line was established, no funding had been attached to it. In response, they declared that they would not pass the annual budget unless the commodities line had funding attached, which drew substantial media coverage. As a result, the MOF allocated approximately US$80,000 to the FP budget. The following year, the MPs kept a critical eye on the MOH and the FP commodities budget line, and worked with the MOH to ensure that the allocated funding was fully disbursed to purchase commodities. They also lobbied both the MOH and MOF for increases in the FP and overall health budgets. In response, the MOH confirmed that it would more than double its request for FP in the FY14–15 budget, and would also increase the overall health sector budget request by more than 50 percent. Now that the MPs have identified the allocation step as a potential barrier, they are better prepared for ongoing efforts to ensure funding. August 2014 4 US$3.2 million in FY12–13 to US$6.9 million in FY13–14. To increase the buying power of this new funding, parliamentarians also secured an amendment to the Tax Act so that health commodities distributed in public sector facilities are not taxed. The Health Policy Project is a five-year cooperative agreement funded by the U.S. Agency for International Development under Agreement No. AID-OAA-A-10-00067, beginning September 30, 2010. It is implemented by Futures Group, in collaboration with Plan International USA, Futures Institute, Partners in Population and Development, Africa Regional Office (PPD ARO), Population Reference Bureau (PRB), RTI International, and the White Ribbon Alliance for Safe Motherhood (WRA). The information provided in this document is not official U.S. Government information and does not necessarily represent the views or positions of the U.S. Agency for International Development. Contact Us Health Policy Project 1331 Pennsylvania Ave NW, Suite 600 Washington, DC 20005 Case Study: Uganda In late 2012 and early 2013, a group of Ugandan MPs, in consultation with the MOH and civil society, focused on how they could help implement their government’s FP2020 commitment to increase the national budget for reproductive health commodities from US$3.3 million to US$5 million annually. Collectively, the three groups developed a strategy to select individual MPs, based on their committee assignments and backgrounds, who would be responsible for budget tracking, quarterly reviews of released funds, and personal advocacy with the president to encourage him to recommit to his funding pledge. The parliamentarians also joined other stakeholders on a task force to ensure that the activities were carried out. They were successful in implementing the FP2020 commitment—the domestic budget for FP more than doubled, from Conclusion Experience in several countries shows that engaged and committed parliamentarians can be a strong force in motivating FP funding and policy improvements. While many MPs are natural advocates for their constituents’ health and well-being, their diverse backgrounds and demanding portfolios rarely equip them with in- depth or nuanced knowledge of FP issues. Drawing on their own FP expertise, ministries of health and civil society can complement the amplified voice and high- level access MPs provide in a collaboration that offers tremendous potential. With enhanced skills in identifying decisionmakers, using evidence, mapping barriers, and designing advocacy strategies, MPs can become dedicated allies with the MOH in holding governments accountable to their FP2020 commitments. References Lee, R.B., L.P. Nacionales, and L. Pedroso. 2009. “The Influence of Local Policy on Contraceptive Provision and Use in Three Locales in the Philippines.” Reproductive Health Matters 17(34): 99–107. World Health Organization. 2000. The World Health Report 2000: Health Systems: Improving Performance. Geneva, Switzerland: World Health Organization. For more information see separate briefs on working with ministries of health and the private sector: Lipsky, A. and R. Mbuya-Brown. 2014. Stewardship for FP2020: MOH Role in Improving FP Policy Intervention. Washington, DC: Futures Group, Health Policy Project. Lipsky, A., and J. Gribble. 2014. Stewardship for FP2020: Working with the Private Sector. Washington, DC: Futures Group, Health Policy Project. Skill: Design an Advocacy Strategy An effective strategy to achieve policy change must divide a desired outcome into a series of sequential steps that can be completed by a small group of people. Designing an advocacy strategy to meet a country’s FP2020 commitments could include identifying the stages of the national budget process and the points within it when a funding increase must be requested, confirmed, and approved, as well as the agencies and individuals with authority for each. Similarly, a strategy to expand access to FP at lower levels of the health system through task shifting could map the process of conducting necessary research and compiling evidence, presenting it to relevant decisionmakers, and drafting a new policy or regulation. To ensure success, an advocacy strategy should not only include the steps of an action plan, but also identify the individuals who assume responsibility for each step and set a timeline for completion. Importantly, MPs and other government officials are not interchangeable: MPs fill unique roles as representatives of distinct constituencies and members of specific committees that allow them to perform functions other government officials cannot.

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