Social services


GFF falls short on family planning

31 January 2017 | At Issue

Community midwife in badakhshan uses postpartum family planning

A fully-formatted PDF version of this briefing is also available.

at-issue-cover-gffIn 2014 the GFF was announced as a “pioneering” mechanism to finance efforts for reproductive, maternal, newborn, child and adolescent health (RMNCAH) programmes and policies. The GFF was developed as a multi-stakeholder partnership in support of the UN Secretary-General’s Global Strategy for Women’s, Children’s and Adolescents’ Health (the Global Strategy) with the objective to help fill funding gaps for RMNCAH. To date, the GFF has 15 focus countries: Bangladesh, Cameroon, the Democratic Republic of Congo, Ethiopia, Guatemala, Guinea, Kenya, Liberia, Mozambique, Myanmar, Nigeria, Senegal, Sierra Leone, Tanzania and Uganda.

Funding for the GFF comes from donors, which is pooled through the World Bank. Implementation of the GFF is supported by a secretariat which sits at the World Bank. In addition to the secretariat, the GFF is overseen by an investor group responsible for garnering new money and monitoring progress of investments.

The GFF is intended to be country responsive, and therefore funding priorities are to be identified by countries themselves. Country priorities are outlined in GFF investment cases, which are supposed to be country-led, prioritised plans for addressing RMNCAH. These plans are intended to feed directly into the activities and projects identified for funding.

GFF investment cases lay out multiple priorities, but the GFF Trust Fund and complementary funds from the International Development Association (IDA), the Bank’s low-income country arm, will only cover some of these priorities. Priorities that are identified for funding by the GFF Trust Fund are described in Project Appraisal Documents (PADs) developed by the World Bank. Resources for GFF priorities that are not covered by these are supposed to be identified and resourced by other bilateral and multilateral donor funds, and domestic resources; however, it is unclear how funding for the other priorities are identified, and how involved the World Bank or in-country stakeholders and governments are in making those decisions.

GFF investment cases are supposed to be developed and implemented through engagement with a range of stakeholders, including civil society organisations (CSOs) and the private sector, to ensure that GFF funding reflects the priorities of all sectors in the country, and garners local support for the GFF.1 However, this does not reflect the reality on the ground. For example, while the GFF has set minimum standards for inclusiveness and transparency at the country level, there is no requirement that CSOs be included in decision-making processes. Unsurprisingly, CSOs have struggled to engage with the GFF to date. Not only does this undermine transparency and accountability, it increases the chances that GFF priorities will not match the needs of communities.

Priorities poorly translated into funding for family planning

improved-tableThe recently adopted Sustainable Development Goals (SDGs), which include a specific target for ensuring universal access to sexual and reproductive health, need financial support to be realised. Strong family planning programmes, underpinned by the adequate provision of contraceptives, are essential to achieving the SDG targets and the Global Strategy. Fulfilling contraceptive needs and averting unintended pregnancies improves maternal and child health by reducing the number of  abortions, miscarriages, and stillbirths, as well as maternal and child deaths. Unfortunately, family planning is facing a looming contraceptive funding crisis2, some of which the GFF has the potential to mitigate. To better understand how responsive the GFF is to RMNCAH priorities, PAI, a US-based NGO, conducted a review of family planning and contraceptive procurement language in investment cases and PADs. Our detailed findings are included in the forthcoming report, The GFF and Family Planning.3

PAI analysed GFF investment cases and PADs focusing on objectives/results, components/interventions, and indicators because these three areas most closely translate into activities and projects the GFF will fund. Objectives/results identify the overarching goal to be achieved by the GFF, components/interventions define how the GFF programmes will be implemented, and indicators outline how GFF outcomes are measured in-country.

All four of the investment cases analysed, Kenya, Tanzania, Ethiopia and Uganda, included family planning language in the priority interventions and indicators. For example, Kenya, Tanzania and Uganda specify increasing the use of modern methods of family planning in their interventions. All of the investment cases also included more than one family planning indicator. However, family planning language was not present in the investment cases’ results sections, with the exception of Tanzania’s investment case. Tanzania’s results mention contraceptive procurement, which is the only investment case to mention contraceptives.

The five publically available PADs — Kenya, Tanzania, Nigeria, Cameroon, and the Democratic Republic of the Congo — were also analysed to determine which priorities or activities outlined in investment cases will receive GFF Trust Fund support. The research for the PADs focused on the same areas as that of the investment cases.

Disconnected plans and unanswered questions

While every investment case reviewed included family planning language, family planning is largely absent from the PADs. Three of the PADs analysed have no family planning language present; this includes Tanzania, which has strong family planning language present in its investment cases. Kenya and Cameroon’s PADs are the only two that include family planning. Surprisingly, Kenya’s PAD names contraceptive procurement as a key project component, but no contraceptive procurement language is in its investment case. Cameroon’s PAD also mentions contraceptive procurement in its component, but it is more broadly related to addressing bottlenecks and constraints of RMNCAH pharmaceuticals. None of the other areas across the PADs address contraceptives.

This analysis raises questions about how well investment cases translate into actual investments. While it is important to ensure that local stakeholders use investment cases to reflect the importance of family planning, this does not actually matter if no family planning programmes are funded. If family planning is not present in the PADs, family planning programmes will not receive any new GFF funding. Of the two countries that developed investment cases prior to the PADs (Tanzania and Kenya), it appears that only Kenya’s language on family planning carried through from its investment case to the GFF-funded project. Tanzania has some of the strongest family planning language within its investment case as one of the only countries with family planning results. However, when translated to the PAD, there is no mention of family planning within its objective, components or indicators. This means that a country could prioritise family planning in the investment case, but not receive any funding from the GFF Trust Fund to implement family planning activities.

Shifting goal posts

Lack of transparency is another issue. Following recent complaints about the poor translation of family planning language into projects identified for GFF funding, the GFF secretariat has begun to describe the GFF as a pie, where the GFF Trust Fund and IDA will cover only a “slice,” or part of the priorities laid out in a country’s GFF investment case. The other donor organisations or countries are expected to take the other slices of the pie, but it’s unclear who gets to decide which priorities the GFF will fund. Once an investment case is done, advocates are in the dark about funding agreements that countries make with the GFF and other donors.

It is worrisome that these decisions around prioritisation and funding are made behind closed doors, without broad stakeholder engagement, because it means that some important programmes or constituents, including CSOs, may not have a voice. Individuals and institutions have their own priorities for funding and sometimes neglect areas that are important for the health of a community or country. Furthermore, without knowing which funders have committed to which “slices of the pie,” civil society cannot play its important accountability role ensuring that commitments are fulfilled.

Additionally, for programmes that are not included in the PADs, there remain questions about how to ensure that another donor will cover the remaining components of the investment case. The GFF should provide guidance to governments to ensure that donors are coordinated in taking up all of the components of the investment case. Otherwise, this lack of coordination results in uncertainty, particularly for programmes that are historically neglected but are critical to improving maternal and newborn health, such as family planning.

Sequencing raises further questions about how well investment cases are shaping actual GFF investments. Three countries have not yet completed their investment cases, but priorities have already been identified to receive GFF  investments as described in the PADs. This undercuts gaining broad stakeholder ownership of priorities for GFF funding.

Civil society can help make investments count

The GFF requires additional work to ensure that important RMNCAH components —particularly family planning — are being funded. PAI’s recent review is limited to the number of countries that have completed and made public their investment cases, as well as those that have had GFF funding already identified for them through a PAD. However, many countries still have investment cases to complete and opportunities to engage with the GFF Trust Fund.

Part of the reason that investment cases contain strong family planning language is the hard fought work of CSOs. To ensure that investment cases continue to reflect family planning language and priorities, CSOs must continue to contribute to investment cases in every area they can. PAI’s Civil Society Guide to the GFF includes more information and opportunities to engage.4

Advocacy for strong language in investment cases, however, won’t matter if other pieces of the “pie” are not being funded. Therefore, it is important that CSOs have the ability to monitor GFF funding and their sources. For those countries that did not see their priorities translate into PADs, such as is the case for Tanzania, there are opportunities for CSOs to use the investment case priorities to petition the Ministry of Health and World Bank contacts in-country to ensure that their priorities are included in future iterations of funding. Part of this work also includes advocacy to the GFF by all stakeholders, including CSOs, to be brought into discussions on how the GFF is being funded and on which donors are taking which slice of the pie.

The GFF has the ability to fill important gaps in RMNCAH but only if local voices are respected and access to family planning is sufficiently prioritised. PAI’s research indicates that country priorities around family planning may not be sufficiently translating into actual investments. Our findings suggest that despite family planning being a proven and cost-effective investment in improving RMNCAH, prioritisation is not a given in GFF Trust Fund investment cases, nor is it translated into PADs. Moreover, this is unlikely to happen without greater GFF transparency and concerted efforts of civil society to demand inclusion in GFF decision making processes.