Bill & Melinda Gates Foundation
Family planning is a critical part of the Bill & Melinda Gates Foundation’s mission. The foundation is working hard to ensure that every dollar spent on family planning contributes to the FP2020 goal as a critical milestone towards reaching the SDG goal of universal access by 2030. In 2015 the Gates Foundation invested $147.9 million in family planning, staying on track to achieve its financial FP2020 commitments.
The Gates Foundation’s family planning strategy and theory of change are focused on ensuring equitable access to quality family planning services, with programmatic and advocacy investments that work in tandem to advance these efforts.
On the programmatic side, the foundation takes an equity lens to every investment it makes. The Challenge Initiative, launched in 2016, is an example: the program incentivizes countries to replicate a suite of impactful, locally appropriate and scalable interventions aimed at reaching the poorest women and girls in cities across sub-Saharan Africa and South Asia. Currently this program is active in India and Nigeria, with additional East Africa and West Africa regional hubs covering more countries. Similarly, the Gates Foundation is increasing funding to social franchising organizations to expand the reach of family planning programs. The foundation continues to put ample energy into the co-funded Implant Access Program, which aims to increase method mix options for women and girls by expanding access to implants, a previously less accessible family planning option. The foundation is also working with countries to include rights-based language in country plans and to fund evidence-generating work on implementing rights-based programs at the facility level.
On the advocacy side, the Gates Foundation has infused new support to in-country advocacy partners to increase their national and subnational advocacy efforts across 10 geographies (Burkina Faso, Senegal, the Democratic Republic of Congo, Kenya, Uganda, India, Indonesia, Nigeria, Bangladesh, and Tanzania). From November 2015 to July 2016, the Advance Family Planning project achieved more than 49 policy and funding successes through its network of priority countries, partners, and African advocacy networks. In this same time period, they documented $9.9 million in new financial commitments for family planning at the national and subnational levels in 15 countries. This work is critical, particularly at the subnational level, in countries where decentralization means that budget and policy decisions are now made at the local level.
The Gates Foundation will continue to prioritize advocacy for accountability, further focusing its work on increasing political will, global coordination among key partners, and commitments from countries themselves to support family planning programs. One aspect of this advocacy is increasing the use of the foundation’s voice. In June 2016, Melinda Gates and UNFPA Executive Director Babatunde Osotimehin conducted a joint trip to Kenya to create a pan-African accountability moment at the FP2020 mid-point, and to hold up Kenya as an example of progress. They met with key government officials, donors, and influencers to encourage greater collaboration and to advocate for data-driven decision-making. Discussions largely focused on: 1) the importance of government commitment to family planning, 2) the critical opportunity to reach young people with voluntary services, 3) engaging men and religious leaders as champions, and 4) the broader health and economic benefits of family planning.
The Gates Foundation continues to focus on development of new technologies, such as longer-acting injectables, biodegradable implants, very long-acting methods, and novel delivery systems. The goal of the Contraceptive Technology initiative is to address barriers to using contraception through breakthroughs in delivery technology and in novel product development for priority user groups, including: 1) women who don’t want more children, 2) women who don’t use available methods due to side effects, and 3) adolescents and young women. The foundation is also supporting new product introduction, particularly for DMPA SubQ in Uniject (known as Sayana Press). This includes generating relevant evidence to scale new delivery platforms or technologies.
Ensuring access to contraception for adolescents and youth is a key area of work, and the Gates Foundation is driving investments to support the development of novel approaches to improve adolescent and youth sexual and reproductive health. The foundation has partnered with the Lancet Commission to develop the Lancet Commission on Adolescent Health and Wellbeing, which launched in London, DC, Seattle, and at Women Deliver in Copenhagen. In early 2016, the Gates Foundation partnered with Children’s Investment Fund Foundation to launch Adolescents360 (A360), an investment focused on scaling youth-centric approaches to increase voluntary adolescent contraceptive use in Nigeria, Tanzania, and Ethiopia. This four-year, $30 million investment will not only generate hundreds of thousands of new users of voluntary modern contraceptives, but will also catalyze a new way of designing high-performing adolescent sexual and reproductive health programs at scale, using a developmentally and anthropologically informed user-centered design process.
The Gates Foundation has also expanded investments to test interventions that delay first birth and reduce adolescent fertility rates. The foundation is partnering with the Packard Foundation, USAID, UNFPA, Save the Children, Ford, and the World Health Organization on the Global Early Adolescent Study (GEAS), a landmark study that offers a unique opportunity to understand the impact of gender norms on adolescent sexual and reproductive health outcomes. The GEAS will provide the field with essential learnings on very young adolescents and the interventions that have an impact on their long-term health, development, and empowerment outcomes.
In 2015 the UK government reiterated its strong support for family planning through its manifesto commitment to “work to ensure family planning for those who want it.” The UK remains absolutely committed to achieving its own goal of reaching 24 million additional women with voluntary modern contraception by 2020 and therefore contributing to the global goal of reaching 120 million additional women. By March 2015 the UK had successfully reached 9.9 million women, placing it on track to achieve its targets. Financially, the UK has exceeded its FP2020 commitment for family planning expenditures in past years, and expects to remain on course to meet or exceed its £180 million per year commitment.
The UK’s Department for International Development (DFID) will continue to deliver results through a combination of country programs (approximately 17 countries will implement programs focused on reproductive health in the coming spending period), regional programs, and multilateral support. DFID remains the largest donor to the UNFPA Supplies program and is the second largest global procurer of contraceptives after USAID.
DFID is an active technical and financial supporter of global coalitions that are focused on improving access and supply of contraceptives, including the FP2020 Secretariat, the Reproductive Health Supplies Coalition, and the Partnership for Maternal, Newborn and Child Health. DFID is also aligned with the Global Financing Facility, and aims to ensure that all aspects of the RMNCAH continuum of care, including family planning, are represented there.
DFID helped shape the development and adoption of the new Global Goals at the UN General Assembly in September 2015, ensuring that a strong emphasis on tackling gender inequality and “leaving no one behind” would be included. Most of DFID’s family planning programs are focused on the poorest, including a voucher program in Pakistan and specific geographical targeting of poor rural areas in Malawi.
In September 2015 DFID hosted a Youth Summit, drawing young people from the UK and overseas to discuss how to help shape the future. Enabling adolescents to demand and access quality voluntary family planning is becoming an increasing focus in DFID’s work, with more than half of programs featuring components specifically focused on adolescents.
From 2012 to 2016, the Scaling Up Family Planning project in Zambia reached 73,070 additional users of family planning between the ages of 15 and 19. The second phase of the program will include an improved use of data to increase adolescent access (e.g., secondary analysis of DHS and other data to determine and address “hot spots” for teenage pregnancy/early marriage); a focus on multisectoral cooperation and coordination across government ministries to address barriers to family planning access for young people and create an enabling environment; and the establishment of youth-friendly clinics for adolescent sexual and reproductive health.
Despite some success in reaching young people in Ethiopia, unmet need remains high among adolescents. Between 2011 and 2015, DFID invested £18 million in increasing access to reproductive health commodities, with part of the program specifically addressed to young people. The initiative focused on students at universities and colleges and young people located in urban and semi-urban towns, using peer-to-peer counseling and entertainment modalities (poems, music, and dramas) to increase knowledge of family planning and sexually transmitted infections.
In Ghana, DFID is funding a £17 million Adolescent Sexual Reproductive Health (ASRH) program in two regions that aims to improve the reproductive knowledge of adolescents and increase their use of services. In Nigeria, DFID supports access to family planning commodities (including for the adolescent age cohort) through UNFPA.
DFID continues to be a strong advocate for rights and empowerment to be the cornerstone of all FP2020 efforts, and in its country programs works with partners to ensure there are safeguards against coercion and discrimination.
United Nations Population Fund
The United Nations Population Fund (UNFPA) works in more than 150 countries and territories that are home to the vast majority of the world’s people. It is the lead UN agency for delivering a world where every pregnancy is wanted, every childbirth is safe, and every young person's potential is fulfilled. Guided by the 1994 Programme of Action of the International Conference on Population and Development (ICPD), UNFPA partners with governments, civil society, and other agencies to advance its mission. In 2015 UNFPA provided leadership for the integration of the ICPD Programme of Action, including the demographic dividend and family planning, into the 2030 Agenda for Sustainable Development.
UNFPA spent US$341 million—or 42.7% of its resources—on family planning in 2015 (compared with 40.7% in 2014). Reflecting the crosscutting nature of family planning vis-à-vis the different areas of work covered by UNFPA’s mandate, this estimate includes all expenses that contribute to family planning-related results. Of these expenses, US$92.2 million were funded through core contributions and US$248.8 million were funded through noncore contributions. Within the latter, US$155 million (or 45% of UNFPA’s overall family planning expense) was funded through UNFPA Supplies. This highlights the importance of UNFPA Supplies as a key mechanism in meeting the FP2020 goal and the impact that a funding shortage to the program could have on the achievement of that goal.
As an FP2020 core convener, UNFPA is fully engaged in supporting and leading FP2020 efforts at the country and global levels. UNFPA works closely with governments to ensure that country commitments are supported by national policies and strategies and have adequate funding. UNFPA has directly supported the development of a costed implementation plan (CIP) for family planning in several countries, and in 2016 UNFPA worked with the Government of Zimbabwe to develop a national family planning CIP.
At the country level, UNFPA representatives act as FP2020 focal points, coordinating with focal points representing the government and other agencies and helping to drive FP2020 activities. In 2016, UNFPA focal points attended the FP2020 Regional Focal Point Workshops in Asia, Anglophone Africa, and Francophone Africa. UNFPA country offices also actively participated in FP2020 data consensus workshops, reviewing family planning data with government and other stakeholders.
The UNFPA Supplies thematic fund continues to provide intensive support to 46 of the 69 FP2020 focus countries. In 2016, the program has already (as of August 1) provided US$85 million worth of contraceptives to these countries, sufficient to reach over 15 million users and with the potential to avert an estimated 7.7 million unintended pregnancies, 22,000 maternal deaths, 145,000 child deaths, and 2.7 million abortions, of which 2.4 million would be unsafe. The potential savings to families and nations in direct health care costs—the costs of pregnancy and delivery care—are estimated at US$320 million. (Potential impacts were estimated using the MSI Impact 2 model; the results indicated here are service lifespan impacts as opposed to the annual impacts used elsewhere in the report.) UNFPA Supplies is also supporting countries in strengthening their health systems to ensure that a choice of contraceptives is available to women and adolescent girls, especially those in disadvantaged populations.
UNFPA is committed to sustaining increased investments in rights-based family planning, strengthening data on family planning, and building the capacity of countries for supply chain management and delivery of quality family planning services to all, especially adolescent girls and young people. UNFPA will also continue to convene strong partnerships for family planning across all SDGs, leveraging resources for family planning globally and in countries and strengthening accountability for family planning across UNFPA.
United States Agency for International Development
As the world’s largest family planning bilateral donor, the United States Agency for International Development (USAID) is committed to helping countries meet the family planning and reproductive health needs of their people. For over five decades, USAID has concentrated its efforts on enabling couples to determine whether, when, and how often to have children, which is vital to promoting healthy and prosperous families, communities, and nations. USAID’s leadership has furthered the global conversation around family planning and strengthened programming for greater access to modern contraception worldwide. The Agency’s innovative approaches have created one of the greatest success stories in sustainable foreign assistance.
As a founding partner of FP2020, USAID supports the partnership’s goal to reach 120 million additional women and girls in the world’s poorest countries with access to voluntary family planning information, contraceptives and services by 2020. The majority (nearly 80 percent) of the women FP2020 aims to reach live in USAID-assisted countries. Meeting the needs of these women today—and building effective systems to address their needs in the future—will bolster both USAID and FP2020 family planning and reproductive health goals and ultimately empower more women and girls to fully participate in the economic, social, and political progress of their countries.
Expanding Method Choice and Access
Expanding method choice and ensuring women have access to a wide range of contraceptive options means more women are likely to find a method that best suits their needs and lifestyle. In fiscal year 2015, USAID delivered $116 million worth of short-term and long-acting contraceptives and condoms. The USAID-developed Procurement Planning and Monitoring Report monitors contraceptive stock status and shipments for 47 public and private sector programs in 33 countries, increasing the visibility of commodity data for decision making by governments and donors. Since inception of the program in 2008, stock-outs at central medical stores have steeply decreased from 14% to 6%.
USAID’s new $9.5 billion Global Health Supply Chain project focuses on strengthening country-led health supply chains, building local capacity, and improving data visibility to facilitate timely delivery of essential health commodities (including those for family planning) by tracking them down to the last mile.
USAID also continues to support and invest in research and innovative approaches aimed at improving existing contraceptive methods and developing new ones. A new female barrier method, the SILCS diaphragm, received market clearance from the US Food and Drug Administration in 2014 and is now available in 26 countries under the brand name Caya™. Its “one-size-fits-most” design eliminates the need for pelvic exams for sizing and for clinics to stock multiple sizes. Introduction is being planned for several countries in sub-Saharan Africa.
Strengthening Country Ownership
The principles of sustainability underlie USAID’s interventions to accelerate progress in each country. USAID aims to strengthen country ownership and the policy environment for family planning at the country level, including engaging with governments and civil society partners to prioritize investment in family planning services.
For example, USAID has supported development of country-owned costed implementation plans (CIP) in 16 countries, including plans completed recently in Ghana, Uganda, and Ethiopia. USAID provides technical support to ensure that CIPs are developed through a consultative, participatory process that builds ownership among stakeholders and increased technical capacity within the ministry of health to support future implementation and adaptation of the plans. CIPs developed with technical support from USAID have resulted in significant increases in domestic funding for family planning, including the creation of new budget line items for commodities in Niger and Mauritania, and a doubling of the budget for reproductive health supplies in Zambia to $9.3 million. In partnership with FP2020, USAID has supported the development of a suite of tools and resources to support CIP development and execution, including tools to conduct detailed activity-based costing of the strategy and analysis of any funding gaps between available resources and those required to implement the plan as envisioned, which can facilitate further resource mobilization.
Changing Attitudes through Social and Behavior Change Strategies
In many settings, family planning knowledge, attitudes, and behaviors are influenced by social and cultural norms that often discourage the use of family planning services.
USAID’s reproductive health programming prioritizes social and behavior change strategies to support FP2020 goals, with particular focus on the promotion of behavior change that supports healthy reproductive decision making among young people; promotion of male engagement and positive gender norms; and achieving provider behavior change for improved client satisfaction and family planning uptake.
For example, USAID is supporting two important evaluations of family planning-related normative change interventions aimed at young people. The two studies, both of which are being implemented in the Democratic Republic of Congo, explore the impact of interventions that address gender norms and reach adolescents and young adults through schools and faith communities. USAID is also supporting the development and evaluation of an innovative mHealth tool to prepare and encourage individuals and couples to talk with their provider about contraceptive methods. The tool delivers a series of brief role model stories (approximately two minutes each) via phone, along with additional information and questions, to help individuals communicate with their partners, think about their questions, and prepare for family planning counseling.
Another USAID project demonstrates a potentially scalable approach to increasing gender-equitable attitudes and behaviors, reducing gender-based violence, and increasing family planning use among adolescents. The strategy is based on a life course perspective and involves implementing interventions tailored for target age groups. Research shows a 10% increase in family planning use among newly married/parenting couples exposed to the approach. Older adolescents exposed to the approach were also 11% more likely to believe that men and women are equal.