Transitions in Family Planning: Challenges, Risks, and Opportunities Associated with Upcoming Declines in Donor Health Aid to Middle-Income Countries

Publication date: 2019

Transitions in Family Planning: Challenges, Risks, and Opportunities Associated with Upcoming Declines in Donor Health Aid to Middle-Income Countries Transitions in Family Planning: Challenges, Risks, and Opportunities Associated with Upcoming Declines in Donor Health Aid to Middle-Income Countries Pharos Global Health Advisors. 2019. Creative Commons Attribution-NonCommercial 4.0 International Pharos Global Health Advisors 780 Boylston Street, Suite 16J Boston, MA 02199 www.pharosglobalhealth.com Transitions in Family Planning | iii The world of donor aid for health is rapidly changing and will continue to evolve in the coming years, especially in middle-income countries. Donors are reducing their technical and financial support for a range of health issues including HIV, tuberculosis, malaria, and immunization, while at the same time middle-income coun- tries are striving to invest more to preserve the gains they have made against major infectious diseases and to go further to expand coverage and impact. This situation creates a series of acute sustainability challenges for middle-income countries as they approach transition from donor aid. Are country governments ready to take over the financial and technical leadership of these donor-backed programs? Do they have the fiscal capacity to mobilize the additional billions of dollars required to replace donor resources? Do they possess the institutions and the political leadership that will be needed? Will they assume responsibility for donor-sponsored health services directed toward politically- sensitive vulnerable and stigmatized population groups? And where does family planning, which receives US$1.3 billion in annual donor funding, fit into this sustainability and transition landscape? We undertook this study, sponsored by the Center for Global Development with funding from the Bill and Melinda Gates Foundation, because we were concerned that transitions in family planning might be relatively neglected by middle-income countries and donors. Our report, one of the very few to date to examine the chal- lenges of impending transitions in family planning, bears out our initial hypothesis. Our global landscaping and case studies of Ghana, Kenya, and Bangladesh document serious impending sustainability challenges in family planning for middle-income countries and provide a set of recommended actions for country govern- ments and their donor partners to address these challenges. This study builds upon Pharos Global Health’s leadership in health transitions and sustainability. Pharos has conducted more than a dozen country studies in Latin America, Asia, and Africa and has published a wide range of global syntheses, academic papers, and blogs on this topic. We encourage you to go to our website, pharosglobalhealth.com, to access these materials. We hope that this report catalyzes the family planning community—from local officials to global experts—to rigorously and systematically assess and plan for the sustainability and transition challenges that middle-in- come countries’ national family planning programs will face in the coming decade. As we look to 2030, sustainability in family planning is more essential than ever to secure the health, well-being, and empower- ment of millions of women, girls, and their families worldwide. Robert Hecht, President Pharos Global Health Advisors P reface http://pharosglobalhealth.com Pharos Global Health Advisors | iv This report was prepared for the Center for Global Development (CGD) by Devyn Rigsby, Gabrielle Appleford, and Robert Hecht of Pharos Global Health Advisors. The authors thank Janeen Madan Keller, Cassandra Nemzoff, Felice Apter, Julia Kaufman, Kalipso Chalkidou, Amanda Glassman, Hannah Rees, and Cynthia Eldridge for their valuable feedback through- out the preparation of this report. Special thanks also to all interviewees who shared their time and insights for this report. Pharos and CGD are grateful to the Bill & Melinda Gates Foundation for their financial support of this research. All errors and omissions are our own. This report design was prepared by Regina Miles of Studio RM, Inc. The photo on the cover of this report depicts a mother and her son in outside their home in the village of Srimangal, located in the Sylhet Division of Bangladesh. It was taken in February 2013. A uthors & Acknowledgements Transitions in Family Planning | v List of Figures .vi List of Tables .vii Abbreviations .viii Executive Summary .1 Chapter 1: Introduction .11 Problem Statement .11 Methodology.13 Chapter 2: Analytical Framework for Family Planning Transitions .14 Review of Literature .14 Global FP Stakeholder Interviews .21 Analytical Framework . 22 Chapter 3: Global Landscape of Family Planning Transitions . 24 Countries with Long-Term, Low-Priority Transition .28 Countries with Short- to Medium-Term, Lower-Risk Transition .29 Countries with Medium-Term, High-Risk Transition .31 Chapter 4: Ghana Country Case Study . 36 Executive Summary .36 Introduction .38 Financing of FP and Other Health Programs .42 Procurement and Supply Chain .47 Technical Capacity .49 Enabling Factors: Political Commitment to FP and Legal & Human Rights Risks . 50 Summary of Risks and Key Options for Consideration .52 Table of Contents • Table of Contents Pharos Global Health Advisors | vi Chapter 5: Kenya Country Case Study . 56 Executive Summary .56 Introduction .58 Financing of FP and Other Health Programs .62 Procurement and Supply Chain .71 Technical Capacity .73 Enabling Factors: Political Commitment to FP and Legal & Human Rights Risks .75 Summary of Risks and Key Options for Consideration . 77 Chapter 6: Bangladesh Country Case Study . 80 Executive Summary .80 Introduction .82 Financing of FP and Other Health Programs .85 Procurement and Supply Chain .90 Technical Capacity .93 Enabling Factors: Political Commitment to FP and Legal & Human Rights Risks .95 Summary of Risks and Key Options for Consideration .97 Conclusions . 99 Annexes .102 Annex 1: Institutions Represented and Individuals Interviewed for this Report .102 Annex 2: Global Landscape Full Data Table .105 Annex 3: Classification Methodology to Determine Readiness for Family Planning Transition .106 Annex 4: Avenir Health Methodology for Projecting FP Resource Needs through 2030 . 107 Annex 5: OPM External Financing and Co-Financing Trends and Projections for Ghana: 2010-2025 .110 Transitions in Family Planning | vii Figure 3.1: Map of eighty LMICs categorized by family planning transition likelihood and risk.24 Figure 4.1: Ghana’s projected method mix: 2015-2020 .39 Figure 4.2: Projected donor contributions for six priority health programs in Ghana: 2017-2025 .41 Figure 4.3: Estimated and projected donor contributions for FP In Ghana: 2010-2025 .41 Figure 4.4: Total and percent change in new FP uptake by method following the initiation of the Ghana NHIS pilot .42 Figure 4.5: FP financing gap projections in Ghana .43 Figure 4.6: Ghana’s projected co-financing requirements: 2017-2025 .45 Figure 4.7: FP commodity financing gap in Ghana: 2016-18 .48 Figure 5.1: mCPR by Kenya county, superimposed on the theoretical S-curve of mCPR growth .59 Figure 5.2: Kenya method mix estimates for 2015 and 2016 .59 Figure 5.3: FP commodities share of CYPs in Kenya .60 Figure 5.4: GoK actual budgetary spending on health and health as a percentage of total approved GoK budget .61 Figure 5.5: Kenya external spending as a percentage of THE and GDP .61 Figure 5.6: Kenya FP commodity funding 2010-2016 .62 Figure 5.7: FP Spending by financing source in Kenya .63 Figure 5.8: Kenya FP commodity funding 2010-2020 .64 Figure 5.9: Commodity funding gap analysis in Kenya .65 Figure 5.10: Projected FP resource requirements in Kenya assuming constant donor funds: 2019-2030 .67 Figure 5.11: Projected FP resource requirements in Kenya assuming a 50% reduction in donor funds over ten years: 2019-2030 .68 Figure 5.12: Ten Kenya counties with the highest and lowest aggregate facility month of stock (stock on hand) for injectable contraceptives.72 Figure 6.1: Breakdown of 2016 Bangladesh FP expenses by category .85 Figure 6.2: Funding sources of selected programmatic areas in Bangladesh .86 Figure 6.3: IDA committed lending amounts to Bangladesh: 2011-2019 .88 List of Figures Pharos Global Health Advisors | viii List of Tables Table ES.1: Three country categories for FP transition risk: unweighted median and range values for six indicators .3 Table ES.2: Transition characteristics of the three case study countries .3 Table 2.1: Documents consulted for literature review .15 Table 2.2: Themes of evaluation and associated lessons/recommendations from USAID FP graduation reviews .16 Table 2.3: Analytical framework for FP transition .23 Table 3.1: Three country categories for FP transition risk: unweighted median and range values for eight family planning and health financing indicators .25 Table 3.2: Family planning and health financing indicators for countries in the long-term, low-priority transition category .26 Table 3.3: Family planning and health financing indicators for countries in the short- to medium-term, lower-risk transition category .30 Table 3.4: Family planning and health financing indicators for countries in the medium-term, higher-risk transition category .32 Table 4.1: Timeline of donor health aid withdrawal in Ghana through 2027.44 Table 4.2: Key options for considerations to improve Ghana’s readiness for FP transition .52 Table 5.1: Projected Kenya FP resource requirements: 2019-2030 .66 Table 5.2: Summary table of priority health program resource needs and expected domestic expenditures in 2018 .70 Table 5.3: Key options for consideration to improve Kenya’s readiness for FP transition .77 Table 6.1: Projected Bangladesh FP resource requirements: 2019-2030 .87 Table 6.2: Recommendations to improve Bangladesh’s readiness for FP transition .97 Table A.1: Categorization scheme for LMIC FP transition preparedness .106 Table A.2: Actual and projected donor expenditure by health area in Ghana, 2010-2025.110 Table A.3: Actual and projected co-financing requirements by health area in Ghana, 2010-2025 .113 Transitions in Family Planning | ix AIDS Acquired immunodeficiency syndrome ART Anti-retroviral therapy AW All women BCC Behavioral change communication BDHS Bangladesh Demographic and Health Survey BMGF Bill & Melinda Gates Foundation BTL Bilateral tubal ligation CCM Country Coordinating Mechanism CDoH County Department of Health CGD Center for Global Development CHAG Christian Health Association of Ghana CHAI Clinton Health Access Initiative CHPS Community-Based Health Planning and Services CIFF Children’s Investment Fund Foundation CIP Costed Implementation Plan CSO Civil society organization CYP Couple-year of protection DAH Development assistance for health DFID Department for International Development (U.K.) DGFP Directorate General of Family Planning DGHS Directorate General of Health Services DHIS2 District Health Information System 2 DHS Demographic and Health Survey DMPA-SC Subcutaneously administered depot-medroxyprogesterone acetate (Sayana Press) DP Development Partner DQA Data quality audit DRC Democratic Republic of the Congo DRM Domestic resource mobilization ECA Europe and Central Asia eLMIS Electronic logistics management information system EMMS Essential medicines and medical supplies ESP Essential Service Package EU European Union FFS Fee-for-service FP Family planning FP2020 Family Planning 2020 FPSA Family Planning Spending Assessment FWV Family Welfare Visitor FY Fiscal year GDHS Ghana Demographic and Health Survey GDP Gross domestic product GF Global Fund GFF Global Financing Facility GHE Government health expenditure GHED Global Health Expenditure Database (WHO) GHS Ghana Health Service GNI Gross national income GoB Government of Bangladesh GoG Government of Ghana GoK Government of Kenya Abbreviations Pharos Global Health Advisors | x • Abbreviations HIV Human immunodeficiency virus HMIS Health Management Information System HPV Human Papillomavirus HR Human resources HSS Health systems strengthening HSSP Health Sector Support Program HTA Health technology assessment ICC-CS Interagency Coordinating Committee for Contraceptive Security IDA International Development Association IEC Information, education, and communication IHME Institute for Health Metrics and Evaluation (Washington, U.S.) IPPF International Planned Parenthood Federation IUD Intra-uterine device JICA Japan International Cooperation Agency JSI John Snow, Inc. KEMSA Kenya Medical Supplies Authority KES Kenyan shillings KfW Kreditanstalt für Wiederaufbau (German Development Bank) KOFIH Korea Foundation for International Healthcare LAC Latin America & Caribbean LAPM Long-acting and permanent method LARC Long-acting reversible contraceptive LMIC Low- and middle-income countries LMIS Logistics management information system LSO Logistics Support Officer M&E Monitoring & evaluation MC Male condom MCH Maternal and child health mCPR Modern contraceptive prevalence rate MDG Millennium Development Goal MEDS Mission for Essential Drugs and Supplies MENA Middle East and North Africa MoH Ministry of Health MoHFW Ministry of Health and Family Welfare MoLGRDC Ministry of Local Government, Rural Development, and Cooperatives MR Menstrual regulation MRM Menstrual regulation with medication MSB Marie Stopes Bangladesh MSI Marie Stopes International MW Married women NACC National AIDS Control Council NASA National AIDS Spending Assessment NCD Non-communicable disease NGO Non-governmental organization NHA National Health Accounts (WHO) NHIA National Health Insurance Authority NHIF National Hospital Insurance Fund NHIS National Health Insurance Scheme NIDI Netherlands Interdisciplinary Demographic Institute NPC National Population Council OBA Output-based aid OOP Out-of-pocket OPM Oxford Policy Management OPRH Office of Population and Reproductive Health PEPFAR President’s Emergency Plan for AIDS Relief (U.S.) PFM Public financial management PHC Primary health care PMI President’s Malaria Initiative (U.S.) PPAG Planned Parenthood Association of Ghana PPFP Postpartum family planning PSI Population Services International PSM Procurement and Supply Chain Management R4D Results for Development RH Reproductive health RHSC Reproductive Health Supplies Coalition RMHSU Reproductive and Maternal Health Services Unit RMNCAH Reproductive, maternal, newborn, child, and adolescent health Transitions in Family Planning | xi • Abbreviations SBS Sector budget support SDG Sustainable Development Goal SDM Standard Days Method SIAPS Systems for Improved Access to Pharmaceuticals and Services SMC Social Marketing Company SRH Sexual and reproductive health SWAp Sector-wide approach TA Technical assistance TB Tuberculosis TFR Total fertility rate THE Total Health Expenditure THS-UC Transforming Health Systems for Universal Coverage TMA Total market approach TWG Technical working group UHC Universal health coverage UN United Nations UNFPA United Nations Population Fund UNPD United Nations Population Division UPHCSDP Urban Primary Healthcare Services Delivery Project USAID U.S. Agency for International Development USD U.S. dollars WAHO West African Health Organization WB World Bank WHO World Health Organization WRA Women of reproductive age Pharos Global Health Advisors | 1 Executive Summary The FP Transition Challenge Transition from donor aid—the process of countries shifting from dependence on outside funding and other technical assistance towards greater domestic self-suffi- ciency in financing and program stewardship—is a defin- ing feature of the current global health landscape. Health transitions are occurring across a variety of donor-backed health programs, including in HIV, tuberculosis, malaria, immunization, and family planning. The roughly US $39 billion in annual development assistance for health— including investments from major donors such as Gavi, the Global Fund, the US, the UK, and others¹—is shifting from middle-income countries to the poorest nations with the highest burdens of disease. Gavi has graduated over a dozen nations from immunization support since 2014; 11 countries are expected to transition from Glob- al Fund assistance in 2020, with 11 more by 2025; and USAID has graduated 24 nations from family planning aid. As countries see their outside funding decline, they face major challenges in financing and sustaining crucial health initiatives with their own resources. If donor funds and technical assistance are not adequately replaced, coverage of vital services for the millions of people rely- ing on these health programs may fall. Simultaneous declines in aid for multiple health programs—when donors pull back at the same time in several health areas such as HIV and immunization— pose particularly difficult challenges to middle-income country governments because of the competing finan- cial, programmatic, and political pressures associated with each transition. The complexities of multiple aid transitions are compounded by limited fiscal space for health, rising levels of international debt, limited health governance capacity, and sometimes conflicting devel- opment priorities and policy commitments.2 This report assesses the impact of simultaneous health transitions upon the sustainability and success of family planning (FP) programs in middle-income countries. Universal access to family planning is crit- ical to the achievement of multiple Sustainable Devel- opment Goals, including those relating to women’s and children’s health, gender equality, and the improvement of women’s economic opportunities.³ Because of its benefits both within and beyond the health sector, FP has been a major focus area of international health aid for decades; donors currently contribute about US $1.5 billion annually to FP programs.4 However, transition in family planning may be on the near- to medium-term horizon for a number of middle-in- come nations, especially for a group of approximately 20 lower-middle-income countries. In these countries, demand for contraception is increasing while donor assistance for FP is on the decline. At the same time, domestic co-financing for other donor-backed health programs is on the rise. Governments and their devel- opment partners must plan strategically to sustain equi- table, affordable, and high-quality FP programs in the face of demographic, fiscal, political, and programmatic pressures associated with health transition. 1  IHME (2019). Financing Global Health 2018: Countries and Programs in Transition. IHME, Seattle, WA, USA. 2  Yamey, G., Gonzalez, D., Bharali, I., Flanagan, K., & Hecht, R. (2018). Transitioning from foreign aid: is the next cohort of graduating countries ready? Duke University Center for Policy Impact in Global Health. 3 See: https://www.cgdev.org/sites/default/files/reproductive-choices-life-chances-new-and-existing-evidence-impact-contraception-women.pdf 4 Wexler, A., Kates, J., & Lief, E. (2019). Donor Government Funding for Family Planning in 2018. Kaiser Family Foundation. https://www.cgdev.org/sites/default/files/reproductive-choices-life-chances-new-and-existing-evidenc Transitions in Family Planning | 2 • Executive Summary Study Purpose and Approach The purposes of this study are to: (a) identify specific challenges to FP program sustainability in the context of competing fiscal and programmatic pressures across the health sector; (b) offer forward-looking, practical options for national stakeholders to manage risks associated with competing pressures of multiple upcoming health transitions; and (c) propose practical recommendations for donors to allocate resources and share responsibilities more effectively and transparently in preparation for FP program transition. As part of the study, we reviewed the transition literature for FP and other health programs and interviewed over a dozen global FP leaders and experts (see Annex 1: Insti- tutions Represented and Individuals Interviewed for this Report). We found that, in contrast to other major donor- backed health programs such as HIV, where consid- erable work has been done to analyze country transi- tion risks and responses, there is no broadly accepted framework to assess FP transitions, and limited nation- al assessment work has been carried out. We therefore developed and applied an analytical framework based on four dimensions of FP transition: 1. Financing for FP and Other Health Programs: We assessed fiscal space, health and FP financing sources, and projected resource requirements in the context of simultaneous transitions and nation- al health reforms including the pursuit of universal health coverage (UHC). 2. Procurement and Supply Chain: We evaluated domestic capacity and mechanisms for forecast- ing, procurement, warehousing, and distribution of FP and other health commodities, and we identified strategies for the effective transfer of procurement and supply management to national governments. 3. Technical Capacity: We examined technical assis- tance (TA) provided by donors to FP and other health programs in areas such as training, research and surveys, monitoring and evaluation, and quality assurance, and we proposed measures to smooth the transfer of donor-backed TA activities to nation- al institutions. 4. Enabling Factors: Political Commitment to FP and Legal & Human Rights: We reviewed national policies and laws related to FP, domestic political commitment to FP goals, and the links between FP and other development and human rights goals, which contribute to an enabling environment for individuals to access contraception. Using data for over 25 macroeconomic, health, and FP indicators, we examined the global health and FP tran- sitions landscape and assigned 80 low- and middle-in- come countries (LMICs) to one of three groups: 35 coun- tries with high donor dependency and low likelihood of FP transition in the coming years, and thus facing few transition risks in the short to medium term; 23 coun- tries with low donor dependency and higher per capita gross national income (GNI) and health spending, where FP and other transition is ongoing or near completion and unlikely to be very risky; and, most importantly, a group of 22 countries with moderate incomes and high- er donor dependency that are facing a drawdown of donor support in the next 5-10 years, resulting in signif- icant transition risks for FP and other health programs. Table ES.1 provides unweighted medians and ranges for six relevant FP, health, and financing indicators across the three transition categories. Pharos Global Health Advisors | 3 • Executive Summary TABLE ES.1: Three country categories for FP transition risk: unweighted median and range values for six indicators Country Tran- sition Category GNI per Capita (USD) Total Fertility Rate Modern Contraceptive Prevalence Rate Percent Unmet Contraceptive Need Share of HIV Spending from Donors Donor Expendi- ture on FP per WRA (USD) Source: World Bank, Atlas Method (2017) World Bank (2017) FP2020 Annual Report (2018) & World Bank (since 2012) FP2020 Annual Report (retrieved 2019; various years) UNAIDS GAM (retrieved 2019) IHME (2017); UN World Population Prospects (2015) Long-term, low-priority transition (n=35) 680 (280–2100) 4.70 (2.87–7.18) 19.80 (2.74–46.60) 28.10 (18.30–39.80) 90.5% (41.3–100.0%) 1.21 (0.02–8.37) Medium-term, higher-risk transition (n=22) 1525 (800–3570) 3.23 (1.95–5.62) 31.79 (2.74–65.50) 24.95 (9.90 – 36.92) 81.2% (39.1–95.6%) 0.73 (0.00–4.01) Short- to medium-term, lower-risk transition (n=23) 3540 (1790–5430) 2.34 (1.23–4.31) 45.51 (25.75–68.00) 18.72 (8.54–35.30) 46.1% (1.8–95.7%) 0.03 (0.00–3.58) We then applied our analytical framework and find- ings from the global landscape to three country cases: Ghana, Kenya, and Bangladesh. These nations were selected because they come from the group of coun- tries where FP transition is imminent and will likely pose significant difficulties, and because these countries illustrate the heterogeneity of transition circumstanc- es and challenges facing this cohort. Table ES.2 below captures some of the key indicators and features of the three case study countries in relation to FP transition. For each case study country, we conducted a literature review and interviewed experts from government, donor agencies, and non-governmental agencies (NGOs) during field visits to Ghana and Kenya and remotely for Bangladesh. We collected qualitative and quantitative data from national strategic plans, financial models and records, and health program performance reports. We synthesized our findings and identified key risks and recommendations for the three countries to manage their upcoming FP transitions. Transitions in Family Planning | 4 • Executive Summary TABLE ES.2: Transition characteristics of the three case study countries Ghana Kenya Bangladesh Economic and Demographic Indicators Gross National Income per Capita $1,880 $1,460 $1,470 Women of Reproductive Age (millions) 6.9 12.1 43.5 Annual Population Growth Rate 2.19% 2.31% 1.05% Quantitative Family Planning Indicators Modern Contraceptive Prevalence Rate 22.1% 42.7% 45.5% Total Fertility Rate 3.93 3.79 2.08 Unmet Contraceptive Need 33.6% 20.3% 19.1% % LAPM Methods5 within Total Contraceptive Method Mix 32% 36% 15% Donor Expenditure on FP per Woman of Reproductive Age $1.37 $4.01 $0.75 % Donor Contribution to FP Commodities 90% 51% 4% Qualitative Family Planning Indicators6 Donor Involvement in Procurement & Supply TA Strong Moderate Moderate Donor Support for Enabling Environment Strong Strong Strong Political Commitment to FP Weaker Moderate Strong FP Participation in Health Transition Planning Minimal Minimal Minimal Other Health Transition Indicators % HIV Spending from Donors 63% 63% 96% % Tuberculosis Spending from Donors 76% 52% 84% % Malaria Spending from Donors 44% 53% 77% % Immunization Spending from Donors 65% 77% 73% Sources: World Bank, UN World Population Prospects, FP2020/Track20, IHME, UNAIDS, WHO, Ghana CIP, and Kenya CIP (See Annex 2) 5 LAPMs (long-acting and permanent methods) include sterilizations, IUDs, and implants, according to FP2020. 6 Categories are rated on a scale of: Minimal/Weaker; Moderate; Strong. Ratings are the authors’. Pharos Global Health Advisors | 5 • Executive Summary Key Findings and Recommendations Global FP Transition Landscape • There is a group of middle-income countries under special threat from impending transition in FP and other health areas. These countries have moderate national incomes (in the $1500- 3000 per capita GNI range), have made some progress towards contraceptive coverage goals, and are significantly dependent on donors for funding and technical assistance across a variety of health programs. Ghana, Kenya, Bangladesh are members of this at-risk group. Others include Angola, Congo Republic, Kyrgyz Republic, Vietnam, and Zambia (Table 3.4 shows the full list of countries). • The FP transition risks facing these countries are exacerbated by fiscal pressures caused by concurrent transitions for other global health programs. Domestic “co-financing obligations” may increase by US $5-10 million or more per year for each donor-supported health program, such as immunization and HIV.7 • In the “high risk” FP transition cohort of 22 countries, there appears to be relatively less awareness and/or prioritization of this issue among most government officials and donors involved in family planning, as compared to other diseases. As a result, FP is lagging behind other major health areas, such as HIV, tuberculosis (TB), malaria, and immunization, in terms of transition preparation. Ghana Of the three case study countries, Ghana is the least advanced on the FP transition continuum. Ghana has expressed its ambition to become self-reliant from donor assistance, an important first step in the transi- tion process. However, the government has not devel- oped concrete plans to achieve this goal in the health sector or for FP specifically. • Ghana’s FP indicators and FP governance capacity are weaker compared with its cohort of middle-income peers; its unmet contraceptive need of 33.6% exceeds its modern contraceptive prevalence rate (mCPR) of 22.1%, though its method mix is relatively balanced with long-acting and permanent methods constituting about one- third of the mix.8 Until 2018, the Government of Ghana did not fund FP commodities, and currently the country only pays for about 10% of the roughly $10 million spent annually on contraceptives.9 USAID and UNFPA are heavily involved in procurement and supply chain management in Ghana; donors manage commodity procurement and distribution, and support forecasting, and technical assistance. • Validated FP expenditure data is not available for Ghana. In contrast to Kenya and Bangladesh, Ghana has not completed a comprehensive Family Planning Spending Assessment (FPSA), so it is not possible to assess or monitor the country’s progress towards self-financing. • Interviewees from Ghana’s government, partners, and civil society appeared to be the least concerned about the risks and consequences of FP transition. This attitude may result from a lower prioritization of the transition challenge in Ghana, in part because the government and partners view full FP transition as a distant event. Ghana’s FP stakeholders and partners have not yet begun to develop a transition strategy, in contrast to other large donor-backed health programs in the country such as immunization for which transition assessments have been carried out. • Like Kenya and Bangladesh, Ghana faces growing fiscal pressures in health because of increasing co-financing obligations for other major programs. By 2025, the government’s total co- 7  See, e.g.: MoH and Oxford Policy Management, 2018. A roadmap for sustainability and transition from external finance: mapping donor and domestic financing for the health sector in Ghana and planning for the future; and Gavi, 2019. Key Information on Co-financing for Bangladesh. https://www.gavi.org/sites/default/files/document/co-financing-information-sheet-bangladeshpdf.pdf 8  FP2020, 2018. Core Indicators. FP2020 Data Dashboard. http://www.familyplanning2020.org/data-dashboard 9  MoH and Oxford Policy Management, 2018. A roadmap for sustainability and transition from external finance: mapping donor and domestic financing for the health sector in Ghana and planning for the future. https://www.gavi.org/sites/default/files/document/co-financing-information-sheet-bangladeshpdf.pdf http://www.familyplanning2020.org/data-dashboard Transitions in Family Planning | 6 • Executive Summary financing requirements to Gavi, the Global Fund, and PEPFAR are estimated to reach US $350 million—equal to 70% of all domestic expenditures for health in 2016.10 As these fiscal obligations accumulate, they could put family planning funding at serious risk. The large infectious disease programs are also vying for inclusion in Ghana’s National Health Insurance Scheme (NHIS) alongside FP. NHIS funds for FP and other primary health services may be crowded out by these competing demands, especially since the HIV, malaria, and immunization programs have strong lobbies inside the country and in the donor capitals. To address these FP transition challenges, our report proposes several actions that Ghana and its donor part- ners can take, including: • Introducing a national FP budget line and conducting FP expenditure monitoring along the lines of the Family Planning Spending Assessments being carried out in other countries; • Developing and enforcing FP commodity co- financing requirements to ensure sustained domestic investment in FP; • Reaching an agreement among FP stakeholders on a timeline for transitioning procurement and supply management responsibilities from donors to the government; • Using health technology assessment more systematically to evaluate the inclusion of FP services in the NHIS benefits package; • Developing a comprehensive health sector-wide transition strategy with input from government and partners in all major health programs, including FP; and • Advocating for greater domestic family planning investment with senior health and financing officials by presenting the results of impact and “rate of return” modeling. Kenya Kenya was at one time a leader in domestic financing and management of FP programs: the government introduced a national FP commodities budget line in 2004/05 and financed about half of all FP commodi- ties by 2012/13.11 Long-acting and permanent methods comprise over one-third of the national method mix, and this share is growing.12 The national government continues to recognize and promote rights-based FP discourse. FP commodities are procured, stored, and delivered through the government-run KEMSA supply chain; unlike in Ghana, partners in Kenya provide only limited TA for these activities. • Devolution of power from the national government to Kenya’s 47 counties in 2013 has reversed much of this earlier progress towards self-reliance in FP. Devolution exacerbated existing regional inequalities in FP access and outcomes: while the national mCPR is 45% (all women) and unmet need is 17% (married women), some regions have mCPRs as low as 2%.13 Donor TA is also concentrated in certain counties while others are poorly covered. • Due to a shortage of FP funding from both domestic and external sources, Kenya now faces an FP commodity crisis, with two-thirds of commodity resource needs unfunded in 2019/20.14 Domestic financing of FP commodities has decreased as counties have failed to allocate their funds to FP programs; forecasting has missed the mark because of lack of quality county-level data; and stock-outs have increasingly occurred as KEMSA refuses to distribute FP commodities to counties that have accumulated large arrears. Donors continue to supply the majority of FP program funds, with the latest FPSA showing that three-quarters of all FP spending is coming from outside sources.15 Donors and the government are now developing a matching funds plan to prevent looming nationwide stock-outs and to try to return Kenya to a path towards FP sustainability and self-reliance. 10 Ibid. 11 FP Quantification Technical Reports, 2010-2018. 12 Government of Kenya, Ministry of Health, 2017. National Family Planning Costed Implementation Plan 2017-2020. Nairobi, Kenya. 13 FP2020, 2018. Core Indicators. FP2020 Data Dashboard. http://www.familyplanning2020.org/data-dashboard 14 CHAI, 2019. Kenya FP Commodity Funding Gap Analysis 2018-2021, May 2019. 15 Korir, J. and U. Kioko, 2017. Family Planning Spending Assessment FY 2014/15 – 2015/16. Center for Economic and Social Research, Nairobi, Kenya. http://www.familyplanning2020.org/data-dashboard Pharos Global Health Advisors | 7 • Executive Summary • More than in the other two case study countries, health transition is recognized in Kenya as a high-priority issue, with informants expressing concern about upcoming fiscal obligations in the health sector. Kenya still relies heavily on donor funds for multiple health programs—as of 2017, donors funded 63% of Kenya’s HIV program, for example16—yet the Global Fund and PEPFAR are actively assessing Kenya’s readiness for increased domestic funding on the path to transition. The large and increasing domestic co-financing requirements of these infectious disease programs could threaten the government’s ambitions to achieve universal access to FP and other primary health services through UHC, since HIV, TB, and malaria care currently require more resources than are available in the entire health insurance budget. The HIV program alone is estimated to absorb about US $700 million per year, compared to the 2018 UHC budget of US $352 million.17 • Kenya’s National AIDS Control Council has established a technical working group to plan for transitions holistically across the health sector, placing Kenya ahead of Ghana and Bangladesh in this regard. However, the FP program is not currently represented in this working group and thus has no voice in sector-wide transition discussions. To address these challenges, our report offers sever- al actions that Kenya and its donor partners can take, including: • Re-establishing and funding a national FP budget line according to agreed-upon co-financing arrangements with donors, starting with cost- sharing between government and partners for FP commodities; • Rebalancing the distribution of FP planning and program management responsibility between county and national levels, so that that the national institutions play a larger role; • Naming an FP representative to the national health transitions technical working group hosted by the National AIDS Control Council; • Incorporating a robust mix of FP services in the national health insurance benefits package, drawing on evidence of FP demand and cost- effectiveness; and • Improving equity in FP access across counties and among the underserved through better allocation of donor TA and the use of public- private partnerships (i.e., contracts between government and NGOs to deliver FP services in hard-to-reach situations). Bangladesh Of the three case study countries, Bangladesh is most advanced along the FP transition continuum and is furthest on its way to self-reliance in FP. The govern- ment is currently funding two-thirds of annual FP program costs, including 96% of all commodities.18 Like Kenya, Bangladesh manages its own national procure- ment and supply chain for FP with limited external TA. Due to strong, decades-long political commitment to lowering national fertility, the Bangladesh FP program has received significant prioritization and resources within the health sector. • However, as Bangladesh’s fertility rate reaches near-replacement levels, political will to address other longstanding programmatic challenges related to the FP enabling environment is starting to wane. Under the current Bangladesh FP program, key vulnerable groups such as adolescents and rural and poor women lack sufficient access to FP; the Government of Bangladesh estimates that less than half of married adolescents can access FP, for example.19 • National procurement decisions and a lack of skilled FP providers limit access to effective contraceptives in Bangladesh. Bangladesh’s Directorate General of Family Planning has struggled to recruit and retain an adequate number of trained workers to staff FP facilities. 16 UNAIDS, 2018. AIDSinfo: Kenya. Global AIDS Monitoring. http://aidsinfo.unaids.org/ 17  Chaitkin, M., O’Connell, M., and Githinji, J., 2017. Sustaining Effective Coverage for HIV, Tuberculosis, and Malaria in the Context of Transition in Kenya. Washington, DC: Results for Development. 18 Hamid, S.A., et al., 2016. Bangladesh Family Planning Spending Assessment (FPSA). Dhaka: Institute of Health Economics. 19 See: https://www.thedailystar.net/news/contraceptive-use-among-married-adolescent-girls http://aidsinfo.unaids.org/ https://www.thedailystar.net/news/contraceptive-use-among-married-adolescent-girls Transitions in Family Planning | 8 • Executive Summary Additionally, due to legal restrictions and government procurement decisions, the available method mix is skewed towards less effective short-term contraceptives. Long-acting and permanent methods (LAPMs) comprise only 15% of the Bangladesh method mix, as opposed to 32% and 36% in Ghana and Kenya, respectively.20 This lack of access to effective contraception has resulted in high rates of unintended pregnancy (50%) and recourse to abortion, including unsafe abortion.21 • While Bangladesh’s basic FP procurement and distribution systems are relatively well prepared for transition, it is not clear that the government is willing to fund and manage the other complementary activities that are crucial for expanding and sustaining the FP program’s historic success. Because of the programmatic weaknesses mentioned above, donors in Bangladesh continue to provide funding and TA for FP enabling environment activities, education, program monitoring, research, quality assurance, interventions for key populations, and staff training. Informants’ greatest worry as they contemplated donor withdrawal was the risk of seeing these enabling activities decline. • Bangladesh’s long-term FP program sustainability is threatened by the looming decreases in donor funding in other parts of the health sector. Major health programs in Bangladesh are heavily reliant on external funding. Transitions in these areas will put strong pressures on the government health budget, potentially impacting FP. For example, Gavi funded 73% of all routine immunization expenses and granted US $93 million for immunization systems strengthening for the period 2019-2022, yet Bangladesh is scheduled to see its Gavi support end in 2026.22 External funds account for 96% of HIV spending, 84% of tuberculosis spending, and 77% of malaria spending.23 Bangladesh informants were not aware of any sector-wide efforts to prepare for simultaneous increase in domestic financing requirements for these programs, including FP. To address these challenges, our report highlights several actions for Bangladesh and its donor partners, including: • Implementing social contracting mechanisms between NGOs and the Bangladesh Ministry of Health and Family Welfare to transfer funding responsibility for NGO-led FP TA and enabling activities from donors to the government; • Developing a consensus-based plan for transferring funding for FP monitoring, supply chain, and quality assurance TA from donors to the government; • Ensuring that evidence for supporting a robust contraceptive method mix (including LAPMs) in any emerging UHC scheme is fully presented to decision-makers; • Rebuilding the training pipeline for skilled FP (especially LAPM) providers to fill vacancies in the national health system; and • Establishing a health sector-wide transition working group with representatives from all major donor-backed health programs including family planning. Given the strength of FP in Bangladesh, FP leaders could potentially initiate and host this working group, as the National AIDS Control Council has done in Kenya. Cross-Cutting Recommendations In addition to the specific proposals for the three case study countries, our report offers five cross-cutting recommendations relevant to all 22 middle-income countries in the cohort facing FP transition in the next several years. Middle-income country governments and donors can each play important roles in implementing these recommendations. 20 FP2020, 2018. Core Indicators. FP2020 Data Dashboard. http://www.familyplanning2020.org/data-dashboard 21  Guttmacher Institute, 2017. Menstrual Regulation and Unsafe Abortion in Bangladesh. Fact Sheets. https://www.guttmacher.org/fact-sheet/ menstrual-regulation-unsafe-abortion-bangladesh#fn0 22  Gavi, 2019. Key Information on Co-financing for Bangladesh. https://www.gavi.org/sites/default/files/document/co-financing-information-sheet- bangladeshpdf.pdf 23  UNAIDS, 2018. AIDSinfo: Bangladesh. Global AIDS Monitoring. http://aidsinfo.unaids.org/ World Health Organization, 2018. Global TB Database. https://www.who.int/tb/country/data/download/en/ IHME, 2019. DAH Database: 1990-2018. http://ghdx.healthdata.org/record/ihme-data/development-assistance-health-database-1990-2018 http://www.familyplanning2020.org/data-dashboard https://www.guttmacher.org/fact-sheet/menstrual-regulation-unsafe-abortion-bangladesh#fn0 https://www.guttmacher.org/fact-sheet/menstrual-regulation-unsafe-abortion-bangladesh#fn0 https://www.gavi.org/sites/default/files/document/co-financing-information-sheet-bangladeshpdf.pdf https://www.gavi.org/sites/default/files/document/co-financing-information-sheet-bangladeshpdf.pdf http://aidsinfo.unaids.org/ https://www.who.int/tb/country/data/download/en/ http://ghdx.healthdata.org/record/ihme-data/development-assistance-health-database-1990-2018 Pharos Global Health Advisors | 9 • Executive Summary 1. It is urgent that the 22 countries facing imminent FP transition risks develop FP transition plans, comparable to the transition assessments and plans that are now widely completed for HIV, TB, malaria, and immunization. This recommendation aligns with current strategic thinking in the USAID and UNFPA FP programs.24 (FP transition planning must also be a component of a larger health sector- wide transition planning initiative – see Recommen- dation 2 below.) FP transition plans should include timelines and specific co-financing requirements to transition FP commodity funding to the government, plans to transfer procurement/supply management and other technical assistance activities to national institutions if necessary, and strategies to protect vulnerable populations, ensure quality of services, and promote human rights throughout the transi- tion period. These plans could be developed as part of existing FP strategic initiatives, such as Costed Implementation Plans (CIPs) or RMNCAH frame- works, or produced independently. Country govern- ments need to take the lead in designing these FP transition plans, while donors can support such country-led efforts with financing and expertise. 2. Governments and donors must promote an inte- grated approach to national transition planning that covers FP and other donor-backed health programs. Currently, discussions of health tran- sition largely take place within individual health program silos. While it is important for each health program to assess its own transition risks and read- iness, transition planning and preparation must also occur across health programs. The collabora- tive development of a health sector-wide transition strategy would ensure that each health program’s plans and goals for the timely transfer of techni- cal capacity and financing responsibility to the national government are feasible in the context of other ongoing transitions. Similarly, when possible, governments and donors should develop health co-financing and/or matching fund agreements collectively such that the total “ask” for domestic health financing is realistic given the country’s fiscal situation. A sector-wide approach to transition would also promote more coherent investments in cross-cutting systems (e.g., commodity forecasting and procurement, supply chains, and health infor- mation systems) that can efficiently sustain a range of health programs, including FP. 3. Increased national ownership of FP and of over- all health transition is imperative to bring togeth- er and coordinate the major domestic and donor FP stakeholders, demonstrate political will for and prioritization of FP, and expand domestic funding for FP, including through co-financing or match- ing funds agreements. National FP leaders must also proactively join the larger national debates surrounding health transitions and the adoption of UHC, so that FP-specific priorities are consid- ered alongside other health programs slated for transition and incorporation in UHC benefits pack- ages. To raise this level of ownership, national FP leaders must make a strong case for the impact and cost-effectiveness of investments in FP to the health community, the Ministry of Finance, govern- ment leaders, and the general public. Donors can help to back such advocacy efforts. 4. Donors must make their policies on FP transition more explicit and their timelines for transition more transparent and predictable, so that coun- tries can plan better for shifts in external support. The criteria and indicator thresholds for FP tran- sition being used by key donors such as UNFPA, USAID, and DFID are hard to discern or unevenly applied across countries. (USAID is currently in the process of revising its FP graduation guidelines.) While major donors’ long-term FP funding streams may be uncertain due to politicized replenishment and allocation processes, these organizations can do more to share medium-term plans for financial assistance and technical involvement at the coun- try level to facilitate informed and coordinated tran- sition planning. 24 USAID, 2018. Family Planning Financing: A Framework for Addressing Strategic Opportunities. Washington, DC. Transitions in Family Planning | 10 • Executive Summary 5. A global working group on FP transition would help to coordinate, guide, and support FP transi- tion preparedness processes at the country level and assist national FP teams as they enter into larger health sector discussions on transition. Composed of senior officials from transitioning countries and representatives of the leading interna- tional players in family planning, including FP2020, UNFPA, WHO, USAID, DFID, other European bilat- eral organizations, the World Bank, and IPPF, this working group could develop guidelines and tools for use at country level, sponsor analytical work and planning, monitor progress, share lessons learned from FP transition, and promote knowledge shar- ing among national and international stakeholders. This body could also represent FP at global-lev- el transition discussions alongside the transition working groups that already exist for other donor- backed health programs. To avoid duplication, the transition working group could be nested within existing FP task forces under FP2020 or other suit- able initiatives. Pharos Global Health Advisors | 11 Problem Statement The cohort of countries expected to transition from development assistance in the upcoming decade may have weaker economic, managerial, and technical capacity to sustain and improve upon progress in health achieved to date through partnership with donor orga- nizations, as compared to the countries that graduated from development aid in the 2010s.25 Health transition can be conceptualized as a continuum of progress towards full domestic responsibility for financing and stewardship of health programs, independent of foreign assistance.26 Simultaneous decline in aid for several major donor-backed health programs poses a partic- ular challenge to transition in this upcoming country cohort because of the competing fiscal, programmatic, and political pressures associated with multiple health transitions. Transitioning countries may have limited fiscal space for health, conflicting priorities and poli- cy commitments within the health sector and among various development sectors, and limited capacities to maintain program infrastructure and service delivery. In this context, major donor-backed health programs are at risk for a lack of adequate funding, programmatic stewardship, and political prioritization during and after transition. This report examines the key risks to sustaining quality family planning (FP) programs in the upcoming cohort of transitioning countries as other major donor-backed health programs simultaneously undergo transition and generate significant pressures across the health sector. Achieving universal access to quality FP services by 2030 is a key objective of the Sustainable Development Goals related to health (Goal 3) and gender equality (Goal 5).27 FP empowers women and couples to make informed decisions regarding their reproductive health and contributes to desired social outcomes across a variety of sectors, such as increasing educational access, improving health outcomes, advancing women’s economic opportunities, and reducing poverty. In recognition of FP’s importance in achieving develop- ment goals, FP is a major area of international health aid, with donors contributing US $1.50 billion to FP program- ming in 2018.28 The U.S. provided the largest share of FP funding in 2018 at 42%, and the U.K. contributed 19%. Other major donors included the Netherlands, Sweden, and Canada.29 The 2018 global FP funding level repre- sented an increase from previous years, but this was attributed primarily to U.S. disbursement patterns rather than heightened donor support for FP.30 Moreover, due to changing domestic policies, sustained FP contribu- tions from the U.S. remain uncertain.31 Chapter 1: Introduction 25  Yamey, G., Gonzalez, D., Bharali, I., Flanagan, K., & Hecht, R. (2018). Transitioning from foreign aid: is the next cohort of graduating countries ready? Duke University Center for Policy Impact in Global Health. 26  The Global Fund (2016). The Global Fund Sustainability, Transition, and Co-Financing Policy, Revision 1. 27  SDGs 3.7, 5.6 28  Wexler, A., Kates, J., & Lief, E. (2019). Donor Government Funding for Family Planning in 2018. Kaiser Family Foundation. 29  Wexler, A., Kates, J., & Lief, E. (2019). Donor Government Funding for Family Planning in 2018. Kaiser Family Foundation. 30  Wexler, A., Kates, J., & Lief, E. (2019). Donor Government Funding for Family Planning in 2018. Kaiser Family Foundation. 31  Center for Global Development and Kaiser Family Foundation (2018). The USG International Family Planning Landscape: Defining Approaches to Address Uncertainties in Funding and Programming. Discussion summary. Transitions in Family Planning | 12 • Chapter 1: Introduction As countries in the upcoming transition cohort experi- ence increases in national incomes, they are expected to adopt greater roles in financing and stewardship of their FP programming. This process of FP transition in the upcoming cohort of LMICs poses several risks and challenges that threaten current and future gains in contraceptive quality, access, and usage. First, tran- sitioning countries may not be able to mobilize the domestic resources necessary to fill the gap in FP financing left by exiting donors, particularly since many LMICs are heavily dependent on international funding for FP commodities and other programmatic elements. This challenge is exacerbated by competing fiscal pres- sures in health, particularly from simultaneous national transitions in other health areas, such as HIV/AIDS and immunization, as well as competing health priorities and policies, such as the introduction of UHC plans or other health financing reforms. Limited fiscal space for health coupled with increasing obligations for a variety of disease programs and health benefits packages may restrict domestic resources available for FP and thus translate into sub-optimal FP outcomes. Additional- ly, FP may not be prioritized politically or fiscally when compared with other high-profile and high-need areas in health or other development sectors, further reducing the chances of adequate domestic resource mobiliza- tion for and sustained political and social commitment to FP. Other serious risks to transition and sustainability in FP include: limited domestic capacity for FP commodity procurement where there is a transition-related switch from international to national purchasing; weak supply chain management and quality assurance systems dependent on outside technical assistance; fragment- ed and inadequate monitoring and evaluation (M&E) systems for FP program indicators and expenditures that rely heavily on donor support; limited governmental oversight of and coordination with the growing private sector for FP; a lack of home-grown institutions and practices to equip countries to make decisions in prior- ity-setting and resource allocation; and legal and regu- latory policies and social norms that fail to protect the rights of women, including adolescents. Previous analyses of FP transitions have primarily focused upon Latin America, offering retrospective recommendations that were specific to the FP sector in this region.32 This report is the first to examine FP transi- tions in the current fiscal environment of simultaneous health transitions and to consider transition challenges in relation to other disease programs, identifying general and FP-specific areas of country preparedness and risk. The purpose of the study is to analyze possible future challenges in FP transitions pragmatically in order to offer forward-looking, feasible options for national poli- cymakers to identify and manage challenges associated with competing fiscal pressures of multiple upcoming health transitions and to address specific risks with- in FP programming throughout the transition period. The study also aims to offer practical suggestions for donors to allocate resources and share responsibilities more effectively and transparently in preparation for FP program transition. While other international health programs, such as Gavi and the Global Fund, sponsor the development of extensive, country-level transition preparedness plans, the FP donor community does not. As such, this report’s contextualized transition assess- ment framework and recommendations may serve as an important template for future transition analyses in the FP space. 32  See, e.g., Alkenbrack & Shepherd (2005) and Bertrand, J.T. (2011). Pharos Global Health Advisors | 13 • Chapter 1: Introduction Methodology In brief, our methodology for conducting this study is as follows, with more details provided in subsequent sections of the report: • In preparation for this study, we developed a comprehensive framework to analyze family planning transitions, utilizing insight from the transition literature derived from a variety of health areas. • We then conducted interviews with global leaders and experts in FP to refine and validate this framework (see Annex 1). These interviews also informed the Global Overview section of this report, which outlines and contextualizes the core trends and challenges relevant to FP transitions in LMICs. • We collected data for over 25 macroeconomic, general health, and FP-specific indicators for all LMICs from various published sources to inform our country landscaping and case studies. We identified trends in the data and classified countries into three categories based on the timeframe for transition and the level of risk the countries face: those with high donor dependency but low likelihood of transition in the coming years (long-term, low-priority transition); countries currently facing a drawdown of donor support with significant transition risks over the next 5-10 years (medium-term, higher-risk transition); and countries with low donor dependency where transition should be relatively easier (short- to medium-term, lower-risk transition). • We applied our analytical framework and global learnings to three country case studies in the second category: Kenya, Ghana, and Bangladesh. These countries were selected because they illustrate the heterogeneity of circumstances and challenges facing this medium-term transition cohort of countries, where the issue of transition is most pressing, and where FP transition planning and policy changes by country governments and donors is most urgently required. • For each of the three countries, we conducted a review of the published literature. For Kenya and Ghana, we carried out field visits and conducted in-country interviews with 20-30 key informants in government, donor agencies, and NGOs, and we conducted remote interviews with six Bangladeshi stakeholders (see Annex 1: Institutions Represented and Individuals Interviewed for this Report). For all three countries, we gathered data from national strategic plans and other quantitative sources, including models from Avenir Health, to analyze current and projected FP expenditures and FP commodity procurement forecasts. We identified and quantified sources of domestic and external support to FP and other health programs such as HIV, TB, malaria, and immunization. Finally, we examined FP program performance within each country context. We complemented these analyses with a wide range of qualitative information from interviews on the processes, problems, strengths, weaknesses, and opportunities for positive change in the three countries to prepare for and manage family planning transition. • We synthesized our results into a comprehensive, contextualized set of risks and associated recommendations for upcoming FP transitions in LMICs. Transitions in Family Planning | 14 To develop a framework of analysis for FP transitions in the context of simultaneous health transitions, we conducted a literature review of transitions in FP and other health areas and interviewed twelve global experts from international donor and policy organiza- tions specializing in health and FP. The results of this research are combined into a transition framework with a consistent set of analytical areas and guiding ques- tions to assess country progress towards successful FP transition. This framework and report are intended to address the FP field’s current lack of transition analyses in a realistic fiscal, political, and environmental context and to offer a new approach for future FP transition stud- ies. The full framework is presented in the third section, following a review of the literature and a discussion of key trends from the global FP stakeholder interviews. Review of Literature A matrix of the 14 documents consulted for this review is presented in Table 2.1, categorized by FP transition, program effectiveness, UHC, and transitions in other priority health programs. Nearly all available studies on FP transitions were consulted;33 this body of literature is small, particularly when compared with the documenta- tion available for other major health program transitions. The following sections describe the primary strengths and takeaways of these documents along with key areas for further analysis. Our FP framework builds upon the insights of previous researchers, engages with emerging areas of study, and fills in certain gaps within the literature, as is explained below. Chapter 2: Analytical Framework for Family Planning Transitions 33  Documents consulted were sourced from one of over 15 databases and websites, including Health Policy Plus, SHOPSPlus, Center for Global Development, and others. The following search terms were used individually and in combination with “family planning”: health financing, commodity security, sustainability, transition, effectiveness, UHC. Pharos Global Health Advisors | 15 • Chapter 2: Analytical Framework for Family Planning Transitions TABLE 2.1: Documents consulted for literature review Type of Analysis Documents Consulted FP Transition: USAID FP Graduation Reviews • Cromer, C., Pandit, T., Robertson, J., & Niewijk, A. (2004). The family planning graduation experi- ence: Lessons for the future.  • Alkenbrack, S., & Shepherd, C. (2005). Lessons learned from phaseout of donor support in a nation- al family planning program: the case of Mexico. • Bertrand, J. T. (2011). USAID graduation from family planning assistance: implications for Latin America. • Ávila, G., Gutiérrez, V., Corriols, M., & Cole, K. (2012). USAID/Nicaragua family planning graduation strategy: final evaluation report. • Shen, A. K., Farrell, M. M., Vandenbroucke, M. F., Fox, E., & Pablos-Mendez, A. (2014). Applying lessons learned from the USAID family planning graduation experience to the GAVI graduation process. Health policy and planning, 30(6), 687-695. Program Effectiveness: CGD-led FP Analyses • Silverman, R., & Glassman, A. (2016). Aligning to 2020: How the FP2020 core partners can work better together. Final report of the Working Group on Alignment in Family Planning. • Center for Global Development and Kaiser Family Foundation (2018). The USG International Family Planning Landscape: Defining Approaches to Address Uncertainties in Funding and Programming. Discussion summary. UHC: An Emerging Area of FP Study • Fagan, T., Dutta, A., Rosen, J., Olivetti, A., & Klein, K. (2017). Family planning in the context of Latin America’s universal health coverage agenda. Global Health: Science and Practice,  5(3), 382-398. • Eldridge, C., & Staples, M.H. (2018). A synthesis of recent learnings on the integration of family planning in universal health coverage schemes. Transition in Other Priority Health Programs: Policies, Frameworks, and Analyses • USAID, 2018. Family Planning Financing: A Framework for Addressing Strategic Opportunities. Washington, DC. • Aceso Global & APMG Health (2017). Guidance for analysis of country readiness for Global Fund transition. • Gavi, the Vaccine Alliance (2018). Gavi Alliance Eligibility and Transition Policy, Version 3.0. • The Global Fund (2016). The Global Fund Sustainability, Transition, and Co-Financing Policy, Revision 1. • UNAIDS, Cambodia AIDS Authority, and Pharos Global Health Advisors (2018). Towards Ending AIDS in Cambodia: Transition Readiness Assessment. Transitions in Family Planning | 16 • Chapter 2: Analytical Framework for Family Planning Transitions USAID-Sponsored Studies of FP Transition USAID was the pioneer in FP transition studies, produc- ing the first reports in this field starting in the early 2000s. These USAID publications are concentrated on LAC nations and are almost exclusively retrospective.34 Due to a lack of available data about these countries’ post-graduation experiences, early reports do not draw conclusions about the effects of graduation on FP program indicators or other social outcomes. Instead, authors typically evaluate each country’s FP graduation process across “common themes” of the FP program and its environment,35 offering lessons and/or recom- mendations for successful transition for each program element. A summary of main themes and associated lessons/recommendations is presented in Table 2.2. Many of these recommendations address important issues—such as the need for earlier initiation of transi- tion planning involving all stakeholders—that continue to challenge current FP transitions, suggesting that donor organizations may not have fully applied these early lessons to subsequent contexts. TABLE 2.2: Themes of evaluation and associated lessons/recommendations from USAID FP graduation reviews Selected Themes of FP Graduation Evaluation Key Lessons and/or Recommendations Domestic Funding of FP36,37,38 • Governments are often unable to fulfill promises to provide free contraceptives and would be better served by adopting a total market approach (TMA) to contraceptive pricing during and after transition39 • Ensure that all FP-related staff in the MoH are funded by the domestic budget before transition • Domestic financial commitment to FP may be challenged by competing political priorities during and after transition Contraceptive Procurement, Service Delivery, and Security40 • Develop and institutionalize government-led FP procurement mechanisms at least three years before graduation so that countries complete at least one full procurement cycle prior to transitioning • Social marketing programs can help to expand the contraceptive market • Efforts to engage the commercial sector in FP procurement and provision are not always successful • Integration of FP into HIV and MCH programming may facilitate transition M&E41 • Countries may need considerable M&E support from donors, post-transition • Donors should institutionalize M&E skills and funding in domestic governments before transition • Donors should provide ongoing TA for data utilization in MoH decision-making 34  See: Cromer et al. (2004), Alkenbrack & Shepherd (2005), Bertrand (2011), Avila et al. (2012). 35  Cromer, C., Pandit, T., Robertson, J., & Niewijk, A. (2004). The family planning graduation experience: Lessons for the future. Submitted by LTG Associates and Social & Scientific Systems to USAID. 36 Alkenbrack, S., & Shepherd, C. (2005). Lessons learned from phaseout of donor support in a national family planning program: the case of Mexico. 37 Ávila, G., Gutiérrez, V., Corriols, M., & Cole, K. (2012). USAID/Nicaragua family planning graduation strategy: final evaluation report. 38 Cromer et al. (2004). 39  A total market approach segments the contraceptive market by income level such that every individual can access FP commodities at a price affordable to her. 40  Cromer et al. (2004), Alkenbrack & Shepherd (2005), Avila et al. (2012). 41  Cromer et al. (2004), Alkenbrack & Shepherd (2005), Avila et al. (2012), Bertrand. J. T. (2011). USAID graduation from family planning assistance: implications for Latin America. Bureau for Latin America and the Caribbean, USAID, 57-67. Pharos Global Health Advisors | 17 • Chapter 2: Analytical Framework for Family Planning Transitions Selected Themes of FP Graduation Evaluation Key Lessons and/or Recommendations Equity for Special Populations42 • USAID should consider funding initiatives that serve vulnerable populations (the poor, indigenous, rural inhabitants, etc.) after graduation • Integration of adolescent RH programming into existing gender-based violence prevention efforts may facilitate transition Coordination and Planning throughout Transition43 • Transition timelines should be lengthy • All stakeholders should be involved in planning for FP graduation • Donors need to be consistent in their messaging surrounding FP transition • Political will to fund quality FP programming requires ongoing advocacy from donors and civil society throughout and after transition • Phaseout plans should be flexible to adapt to changing environments USAID Engagement Post-Transition44,45 • USAID should develop an initiative to maintain contact with graduated countries, providing a channel for continued mentorship and support if needed • USAID should continue to monitor FP indicators and programs in graduated countries • USAID should study FP graduation’s effect on TFR and mCPR in the medium-term in graduated countries The strengths of the USAID transition reports include their rich qualitative detail and their application of lessons to other LAC nations approaching FP transition. All studies offer in-depth descriptions of programmatic successes and challenges before and during transition, supported by qualitative information including in-country interviews. Quantitative data is provided for key FP indicators. Later studies start to apply the lessons from a particular coun- try or set of countries to comparable nations approach- ing FP transition; for example, Bertrand (2011) examines a group of three LAC nations scheduled to graduate in the early 2010s—Honduras, Nicaragua, and Paraguay—and extrapolates their “prospects and challenges of gradua- tion” to the FP programs in three other LAC countries not yet ready for transition: Bolivia, Guatemala, and Haiti.46 With this approach, the report provides more tailored and actionable recommendations for future transitioning countries. However, the USAID FP transition analyses have some limitations. These studies generally examine only one country or region (i.e., LAC) retrospectively. Most anal- yses and recommendations are focused on one donor, USAID, and do not look at the transition policies and preparation of other donors, such as UNFPA and DFID, or of national governments. Moreover, these studies examine FP programming in detail but do not typi- cally contextualize their results within broader nation- al programs and trends. For example, while multiple reports call for increased domestic investment in FP commodity procurement, they rarely note the challenge of mobilizing additional domestic resources for FP in the face of other high-cost priorities both within and outside the health sector. When competing fiscal and/or political pressures are acknowledged, it is generally to encourage continued FP political advocacy. 42  Cromer et al. (2004), Bertrand (2011), Avila et al. (2012). 43  Cromer et al. (2004), Alkenbrack & Shepherd (2005), Avila et al. (2012). 44  Cromer et al. (2004), Alkenbrack & Shepherd (2005), Bertrand (2011). 45  See also: https://www.cgdev.org/sites/default/files/working-itself-out-job-usaid-and-smart-strategic-transitions.pdf 46  Bertrand (2011). https://www.cgdev.org/sites/default/files/working-itself-out-job-usaid-and-smart-strategic-transitions.pdf Transitions in Family Planning | 18 • Chapter 2: Analytical Framework for Family Planning Transitions Additionally, some of the recommendations of these reports do not identify actionable steps to achieve desired results. Multiple authors identify the need for increased donor coordination, for example, but do not provide concrete ideas for how to achieve this goal.47 Avila et al. (2012) provide the most detailed and action- able recommendations to address challenges in Nica- ragua’s FP program post-graduation; for example, this study proposes that at least two staff members per FP facility be trained in the medical supplies logistics infor- mation system prior to transition.48 The Avila report also includes the most quantitative data, allowing for the heightened detail of its FP program recommendations. Overall, the initial LAC USAID transition reports estab- lish a foundation for the field of FP transition analysis. Building upon this foundation, the present study situates upcoming FP transitions in the context of other ongoing transitions in health and increases the use of detailed, rigorous quantitative information, particularly about health financing, in assessing FP transition risks globally and at country level. A 2014 article by Shen et al. is the first FP transition anal- ysis that studies FP graduation in relation to other ongo- ing health program transitions. This article compares the FP and immunization graduation processes, applying lessons from early USAID FP graduations to upcoming Gavi transitions. One of the authors’ most important points concerns differing perceptions of FP and immunization programs: “Political leaders and communities tend to view routine immunization as an essential service, a ‘right’ that should be available to all. In contrast, FP programs are more controversial, with wide-ranging levels of support.”49 This insight—that FP may not be a political or fiscal priority relative to other health programs throughout the process of transition— highlights the importance and urgency of studying FP transition in realistic political and social context. Shen et al. also articulate a set of six “foci” to plan for FP graduation in countries nearing transition: contra- ceptive security, advocacy & political commitment, data for decision-making, equity for special populations, the status of FP in health reform, and institutional capacity & human resources.50 The authors favor this “holistic view” of transition readiness assessment over Gavi’s immu- nization transition policy, which considers only GNI per capita.51 However, while these FP graduation foci are holistic in considering FP transition itself, they do not take into account the context of simultaneous health transitions, for example, by considering the challenge of allocating adequate domestic resources to support FP, immunization, and other donor-backed health programs such as HIV. FP Program Effectiveness A small but growing body of FP transition literature seeks to improve the programmatic and cost-effective- ness of existing FP programs.52 This shift in analysis is prompted in part by the changing political and fiscal climate in donor nations; the current U.S. administra- tion, for example, has proposed zeroing out the budget for USAID FP assistance, and other bilateral contribu- tions are stagnating, raising concerns about adequate resource availability for FP programs.53 The growth in the FP program effectiveness literature is supported by stronger quantitative data collection in FP program- ming and financing. Avenir Health’s Track20 initiative to improve FP M&E activities within the 69 FP2020 focus countries is in part responsible for this increase in avail- able data.54 Two notable papers in this area from the Center for Global Development (CGD), have led new insights in FP financing and M&E. 2016 CGD report concludes that current FP program metrics are not attributable to particular interventions across the “results chain” and recommends that FP initiatives be evaluated rigorous- 47  See, e.g.: Alkenbrack, S., & Shepherd, C. (2005). 48  Ávila et al. (2012). 49  Shen, A. K., Farrell, M. M., Vandenbroucke, M. F., Fox, E., & Pablos-Mendez, A. (2014). Applying lessons learned from the USAID family planning graduation experience to the GAVI graduation process. Health policy and planning, 30(6), 687-695. 50  Ibid. 51 Ibid. 52  See, e.g.: Silverman & Glassman (2016), Center for Global Development and Kaiser Family Foundation (2018). 53  Center for Global Development and Kaiser Family Foundation (2018). The USG International Family Planning Landscape: Defining Approaches to Address Uncertainties in Funding and Programming. Discussion summary. 54  Silverman, R., & Glassman, A. (2016). Aligning to 2020: How the FP2020 core partners can work better together. Final report of the Working Group on Alignment in Family Planning. Pharos Global Health Advisors | 19 • Chapter 2: Analytical Framework for Family Planning Transitions ly and independently to determine their effectiveness in terms of impact and cost, permitting evidence- based prioritization of investments.55 A subsequent CGD publication observes that domestic governments do not currently have incentives (and in fact may face disincentives) to meet co-financing requests for FP; the report suggests that co-financing requirements for FP be established and bundled into an “integrated ask” for domestic government financing for all health programs.56, 57 To date, CGD’s reports have been global in scope and have examined transitions as only one challenge in the broader FP landscape. This report is intended to go further by applying the FP transition and priority-set- ting lens to individual countries facing declining donor support for family planning and other health programs. FP and UHC The FP-UHC literature is still in its early stages, with two recent studies examining FP inclusion in UHC schemes more descriptively rather than analytically.58 Research- ers do not currently have enough data to support certain FP-UHC policies, such as demand-side financing, and evidence-based recommendations are a work in prog- ress.59 Nevertheless, as UHC schemes proliferate in LMICs, this topic constitutes an important new dimen- sion of analysis in need of more research. Transition Policies in FP and Other Donor-backed Health Programs Currently, no widely accepted framework, policy, or process exists to determine country readiness for FP transition. The large number of donors in FP—including UNFPA, USAID, and other bilateral agencies and NGOs, each with their own agendas and funding streams— creates a challenging environment for coordinating and applying a consistent FP transition policy. USAID has utilized certain FP indicator thresholds to assess coun- try readiness for transition. However, countries meeting these thresholds do not always experience USAID FP transition, sometimes due to challenging environmen- tal factors outside the FP program.60 UNFPA does not appear to have published FP transition guidelines. In contrast, other major donor-backed health programs, such as Gavi and the Global Fund, have developed and publicized analytical frameworks and/or policies that assist domestic governments and partners in assess- ing country readiness for transition across a consistent set of metrics.61 USAID Approach to FP Transition. As documented in a 2006 technical note, USAID assesses FP transition read- iness based upon national FP trigger indicators: TFR less than or equal to 3.4 and mCPR greater than or equal to 48%.62 Once a country meets these criteria, the USAID strategy suggests that transition should occur within six years, though revised guidelines currently under devel- opment may lengthen this transition period.63 Many countries, including Peru, Sri Lanka, and South Africa, have met these targets and transitioned from USAID FP assistance.64 However, others nearing or surpassing the trigger thresholds, such as Bangladesh (TFR: 2.08, mCPR: 45.5%), have not yet begun the process of tran- sition.65 Respondents suggest that such countries have remained in the USAID FP program due to considerable enabling environment challenges to their FP programs. To account for relevant FP programmatic elements beyond TFR and mCPR, a recent CGD discussion group proposes several additional factors to consider as part of FP transition readiness assessments, includ- ing: population share of youth, equity of FP coverage, adolescent pregnancy rates, government FP expendi- tures, social norms surrounding FP, and political will to create an “enabling environment” for FP.66 Incorporation 55 Ibid. 56 Center for Global Development and Kaiser Family Foundation (2018). 57 For an innovative use of co-financing in family planning, see The Challenge Initiative: https://tciurbanhealth.org/ 58 See: Fagan et al. (2017), Eldridge & Staples (2018), Appleford & Ramarao (2019). 59 Eldridge, C., & Staples, M.H. (2018). A synthesis of recent learnings on the integration of family planning in universal health coverage schemes. 60 Donor respondent. 61  See, e.g.: Kallenberg et al. (2016), Aceso Global & APMG Health (2017). 62  Center for Global Development and Kaiser Family Foundation (2018). 63 Donor respondent. 64 See: https://www.usaid.gov/global-health/health-areas/family-planning/countries#graduated 65 Donor respondent. 66 Center for Global Development and Kaiser Family Foundation (2018). https://tciurbanhealth.org/ https://www.usaid.gov/global-health/health-areas/family-planning/countries#graduated Transitions in Family Planning | 20 • Chapter 2: Analytical Framework for Family Planning Transitions of these additional factors into USAID’s FP graduation strategy could improve consistency and transparency in transition. USAID is currently in the process of updating its FP graduation guidelines. In November 2018, USAID published a new framework for FP financing designed to “provide strategic direc- tion” for country mission staff involved in FP program- ming.67 Drawing upon lessons from the LAC FP tran- sitions and the emerging FP program effectiveness literature, this framework tailors suggested strategic opportunities in FP financing to a country’s specific health financing maturity level and placement along the theoretical mCPR S-curve. The tactics suggest- ed by this framework—such as increased domestic resource mobilization for FP, the incorporation of FP commodities into health insurance schemes, improved public-private partnerships and social contracting mechanisms to support national FP programs, and the development of multi-stakeholder transition plans for FP68—align with key points of investigation and elabo- ration in the present study. Gavi Approach to Immunization Transition. In contrast to FP, the immunization space has only one major donor, Gavi, which has developed and implemented an explic- it transition path to full domestic financing of immuni- zation programs. All recipient countries classified as low-income by the World Bank contribute US $0.20 per routine vaccine dose supported by Gavi.69 When a nation reaches lower middle-income status, it enters the prepa- ratory transition phase, during which time the domestic government’s contributions for vaccine costs increase by 15% per year.70 When a country’s national income exceeds the Gavi threshold—currently US $1,580—for three consecutive years, it enters the accelerated transi- tion phase, a five-year period in which domestic contri- butions to immunization programs increase to 100%.71 While there are some nuances in the Gavi eligibility and transition policy to address the situation in countries with high per capita income and poor health systems and immunization performance, it is clear, predictable, and consistently applied. Global Fund Approach to HIV, TB, Malaria Transition. Similarly, the Global Fund (GF) has developed explicit criteria for country transition in HIV/AIDS, TB, and malar- ia, based upon per capita income and disease burden. Countries meeting the thresholds for transition are given early warning and provided with a final three year “transition grant” to smooth their path to self-sufficien- cy.72 The GF is also attempting to coordinate its tran- sition processes with other donors, especially the US Government’s PEPFAR and President’s Malaria Initia- tive. The Global Fund is increasingly encouraging coun- tries to undertake “transition readiness assessments” at an early stage, many years prior to the projected end of GF financial support, so that plans for transition and sustainability are well in place. The GF evaluates national programs across five core areas, as outlined by Aceso Global and APMG Health (2017): health financing, epidemiological context, institu- tional environment, service delivery, and human rights & gender.73 The GF analytical framework has been applied successfully in transition readiness assessments for a variety of transitioning countries, resulting in detailed reports of contextualized country risks and actionable recommendations to prepare for transition.74 These publications assist the GF and national governments in priority-setting and strategy development throughout health transitions in HIV, TB, and malaria, and this meth- odology serves as a useful model for the development of the analytical framework for FP transition presented below. 67 USAID, 2018. Family Planning Financing: A Framework for Addressing Strategic Opportunities. Washington, DC. 68 Ibid. 69 See: https://www.gavi.org/about/programme-policies/co-financing/ 70 Ibid. 71  See: https://www.gavi.org/support/sustainability/eligibility/ 72  The Global Fund (2016). The Global Fund Sustainability, Transition, and Co-Financing Policy, Revision 1. https://www.theglobalfund.org/media/4221/ bm35_04-sustainabilitytransitionandcofinancing_policy_en.pdf 73  Aceso Global & APMG Health (2017). Guidance for analysis of country readiness for Global Fund transition. 74  See, e.g.: UNAIDS, Cambodia AIDS Authority, and Pharos Global Health Advisors, Towards Ending AIDS in Cambodia: Transition Readiness Assessment (2018); Global Fund and Pharos Global Health Advisors, Evaluación de la preparación para la transición: Colombia (2019); Aceso Global & APMG Health, Dominican Republic Country Report: Transition Readiness Assessment (2017). https://www.gavi.org/programmes-impact/programmatic-policies/co-financing-policy https://www.gavi.org/support/sustainability/eligibility/ https://www.theglobalfund.org/media/4221/bm35_04-sustainabilitytransitionandcofinancing_policy_en.pdf https://www.theglobalfund.org/media/4221/bm35_04-sustainabilitytransitionandcofinancing_policy_en.pdf Pharos Global Health Advisors | 21 • Chapter 2: Analytical Framework for Family Planning Transitions Global FP Stakeholder Interviews We interviewed twelve FP global stakeholders from donor and research organizations (See Annex 1). The purpose of these interviews was to identify the current issues and ideas relevant to ongoing and upcoming FP transitions in order to inform our analytical framework categories and guiding questions. Twelve key findings and associated recommendations from the global infor- mant interviews are summarized below. These findings were tested in the country case studies in this report and proved to be relevant in a number of country situations. 1. Sustainable financing for FP requires greater domestic contribution to and management of FP resources. Many FP funds exist off-budget, and there are few incentives for increased domestic ownership of and contribution to FP programming when donor presence in the FP space appears indefinite. Shifting FP funds on-budget would permit domestic governments to gain experience in FP fiscal management, while specific, transparent co-financing requirements and donor exit timelines would incentivize domestic investment in FP. 2. Domestic resources for FP are significantly constrained by other simultaneous health transi- tions and fiscal pressures outside health. Donors and governments must coordinate to devise real- istic plans for co-financing and transition from development assistance for health across all priority programs. Continued donor assistance in priority-setting both within and outside the health sector may be required to ensure sustainable health financing during and after transition. 3. Integration of FP within countries’ universal health coverage (UHC) movements poses opportunities and risks. FP transition planning is occurring as countries’ interest in UHC grows. Many proposed UHC plans primarily aim to reduce catastrophic expenditure at the hospital level, which may lead to underinvestment in preventive and promotive care, such as FP. In this context, domestic FP financing is at risk. Additionally, more research is needed to support specific modalities of FP inclusion in UHC packages, such as fee-for-service payment for clin- ical FP methods. 4. FP service provision involves a diverse set of providers, which offers challenges and oppor- tunities. FP services are delivered through the public, private, and NGO sectors. Transitioning countries should consider adopting the total market approach for FP, which would tailor pricing of FP services to various segments of the population based on income, unmet contraceptive need, and other factors. Growth of the private sector in partic- ular may help fill some gaps in FP financing during transition. However, coordinating and monitoring a diverse set of FP providers may be difficult for domestic governments. 5. Transition of procurement arrangements appears tenuous. The current global contraceptive market involves only two main commodity procurers, USAID and UNFPA, an unsustainable long-term arrangement. Transition will require countries to move towards managing procurement themselves. However, individual countries may not receive the bulk purchasing discounts enjoyed by USAID and UNFPA, resulting in higher costs for commodities and possible risks surrounding quality of commod- ities obtained from uncertified manufacturers. Proposed pooled procurement mechanisms across multiple countries or regions may promote self-reli- ance in FP commodity procurement and assist in keeping commodity costs low. 6. Certain donor-government practices and incen- tive structures are inhibiting progress toward country self-reliance. When certain donors exit a country, some governments successfully appeal to other partners to fill commodity or other FP fund- ing gaps rather than providing additional domestic resources. Such arrangements undermine prog- ress towards transition; transition plans should be transparent and involve all relevant country stake- holders to prevent these situations. Additionally, partners should be more cautious in the donation of free FP commodities to national governments. The availability of free contraceptives limits the private sector’s development and disincentivizes national governments in allocating program resources and designing insurance benefits packages with the long-term, “fully loaded” costs of FP in mind. Transitions in Family Planning | 22 • Chapter 2: Analytical Framework for Family Planning Transitions 7. The quality of available FP data is poor, partic- ularly for FP-related expenditures, and contin- ued donor investment in FP M&E is necessary. It is currently difficult to monitor country progress towards FP2020 commitments because of this lack of data, but organizations like Track20 are working to support FP M&E capacity through initiatives such as the FP Spending Assessments (FPSAs). Ulti- mately, data should be collected at the sub-nation- al as well as the national level to evaluate equity in program coverage. A dedicated FP M&E position in the government is necessary to sustain and further gains in FP data quality and availability. 8. The politics of domestic financing for FP are chal- lenging on a social and practical level. The politics of investing in programs that are intimately tied to sex and women’s autonomy are difficult to manage even in progressive contexts. In addition, the rela- tionship between population size and government resources can create tension. For example, in feder- al systems when intergovernmental fiscal transfers are tied to population size, there can be a disincen- tive to enable women to reduce their total fertility. Donors should identify appropriate incentives for political commitment to FP programs that respect the principle of voluntary choice, such as offering a country certification for meeting a certain level of contraceptive demand. 9. Domestic governments’ priority-setting capacity is still nascent, which may result in ill-informed decision-making in health. In the context of limited financial resources for health throughout transition, a lack of priority-setting and appropriate consid- eration of trade-offs may lead to implicit rationing and irrational government spending choices. While health technology assessments (HTA) can gener- ate evidence to define cost-effective benefits pack- ages, inform procurement, and identify appropri- ate pricing and provider payment schemes, many countries have not adopted HTAs or have only nascent priority-setting mechanisms in place. Prior to full transition, donors should help to institution- alize data-driven decision-making practices in the health sector. 10. FP officials in domestic governments need great- er authority and managerial capacity. Govern- ment FP programs should have the power and the financial resources to execute FP programming decisions. Donor TA should be directed towards building domestic FP program capacity to contract with NGOs and CSOs for continued provision of FP services following transition. 11. Tensions exist between a rights-based approach to FP and countries’ fiscal constraints. A rights- based approach to FP, which enables broad choice, is fully embraced by donors and donor financing schemes. In the context of transition, domes- tic governments’ ability to finance staff training programs and an expansive contraceptive method mix to support the rights-based approach may be limited. Donors and governments should devise a realistic transition strategy in which a rights-based approach is optimized in the context of a country’s fiscal constraints. 12. Continued donor investment in demand genera- tion is likely required. For many countries facing an FP transition, contracepting is not the norm, and investment to generate demand for these products is needed to sustain FP coverage. Demand gener- ation is typically a secondary priority for domestic governments and may require continued donor assistance. Analytical Framework In contrast to other priority health programs, there is no broadly accepted framework to analyze FP transitions in the context of health systems, financing, social norms, and politics. To guide analysis in this report, we have developed a four-category FP transition framework, presented in Table 2.3. This framework builds upon the “six foci” outlined by Shen et al., the CGD discussion group’s proposed factors for assessing FP transition readiness, and the Aceso Global & APMG Health GF transition analysis categories. Guiding questions within each category are informed by the global stakeholder interviews as well as other insights from the literature review. Pharos Global Health Advisors | 23 The four categories of analysis are: Financing for FP and Other Health Programs; Procurement and Supply Chain; Technical Capacity; and Enabling Factors: Political Commitment to FP and Legal & Human Rights. These categories are framed within country context of epidemiology, population, and development. Relevant guiding questions are shown in Table 2.3 below. TABLE 2.3: Analytical framework for FP transition Framework for Family Planning Transition Analysis | Pharos Global Health (2019) I. Financing for FP and Other Health Programs • What is the country’s overall macroeconomic and fiscal situation? • What are the past and present sources of FP financing, and are programs needs being met? • What resources are required to meet future FP program needs, and how will they be financed? • What other health transitions are occurring, and what are their present and future resource requirements? Who is/are responsible for financing these other programs? • What opportunities exist to increase cost-effectiveness and program impact in FP and other health areas? • What strategies or plans exist for managing transition of financial responsibil- ity for FP and other health programs? • In what ways are FP and other health programs included in insurance or UHC programs, and with what consequences? II. Procurement & Supply Chain • What organization(s) is/are responsible for FP commodity procurement, warehousing, and distribution? • What FP procurement mechanism is used, and will this platform be available following transition? • In what ways are donors involved in FP procurement and supply chain processes? Is the government prepared to assume responsibility for donor activities in this area during transition? • Who oversees FP commodity forecasting? Is the government prepared to conduct its own FP forecasts? • What procurement and supply chain systems exist for other priority programs, and how are donors involved in those systems? Is the government prepared to assume responsibility for procurement and supply chain in other health areas? • Can FP and/or other priority programs be integrated into existing national procurement and supply chain processes? III. Technical Capacity • What technical assistance in health is being provided for FP and other priority programs, and how can this knowledge be transferred to local institutions? • What is the status of the national health system? Are donors investing in HSS, and will this support continue after transition? • How are priorities established within and beyond the health sector? Do donors provide TA in this area, and will this support continue after transition? • What coordination mechanisms, strategies, or documents exist for donors, governments, NGOs, private providers, and other stakeholders in FP and health generally? Are these mechanisms actually utilized to prepare for FP/ other health transitions? • What M&E systems exist in FP, and how are donors involved in those systems? How can M&E expertise be transferred to local institutions? • What is the quality of the services and commodities provided? How is quality assessed? IV. Enabling Factors: Political Commitment to FP and Legal & Human Rights • Is the government prepared and willing to coordinate, manage, and fund the national FP program and FP-oriented CSOs and NGOs adequately? • Are there high-level political champions for FP? • What is the level of political commitment for FP compared with other health areas and other development sectors? • Is FP considered an important component of national development strate- gies? • Do national laws, policies, and regulations create an enabling environment for FP access and provision, including for a variety of FP methods? • Is access to FP equitable across the population? Are services available for key populations, including youth, rural residents, the poor, and other groups? • To what extent are human rights incorporated into FP policy and discourse? All framed within country context of epidemiology, population, & development Transitions in Family Planning | 24 To contextualize our three country case studies, we examined 80 low- and middle-income countries receiv- ing international development assistance for health (DAH) in FP, including 66 of the 69 FP2020 focus nations.75 When assessing LMICs across a variety of demographic, macroeconomic, fiscal, and family plan- ning-specific characteristics,76 we found considerable heterogeneity, signaling varying levels of economic, social, programmatic, and political preparedness for FP transition. For purposes of this report, we have classified LMICs into one of three broad categories related to their readi- ness and ability to manage FP transition: • countries with low incomes and high donor dependency but low likelihood of FP transition in the coming years (long-term, low-priority transition); • countries with relatively high incomes and low donor dependency, where FP transition is already advanced and donor exit may occur soon, and should be relatively easy to manage (short- to medium-term, lower-risk transition); and • countries with intermediate incomes and currently facing a significant drawdown of donor support with significant FP transition risks over the next 5-10 years (medium-term, higher-risk transition) Chapter 3: Global Landscape of Family Planning Transitions 75  All FP2020 Focus Countries, along with all other countries with GNI per capita less than US $4100, were selected for consideration. The State of Palestine, Western Sahara, and DPR Korea are FP2020 Focus Countries but were excluded due to lack of data. Vanuatu, Kiribati, Cabo Verde, Micronesia, Tonga, Kosovo, and Samoa met the GNI per capita threshold but were excluded from analysis due to limited data. 76  See Annexes 2 and 3 for full classification methodology and data. GNI per capita was selected as the primary macroeconomic indicator; TFR, mCPR, and percent unmet contraceptive need were selected as core FP and demographic indicators; and donor dependency in FP, HIV, immunization, and health generally were selected as primary fiscal/transition indicators. FIGURE 3.1: Map of Eighty LMICs Categorized By Family Planning Transition Likelihood and Risk Country Transition Category   long-term, low-priority transition   medium-term, higher-risk transition   short- to medium-term, lower-risk transition Pharos Global Health Advisors | 25 • Chapter 3: Global Landscape of Family Planning Transitions Table 3.1 presents the three categories of countries, along with the median and range for each of eight family plan- ning and health financing indicators. The countries comprising each of the three FP transition categories are present- ed on the map in Figure 3.1. TABLE 3.1: Three country categories for FP transition risk: unweighted median and range values for eight family planning and health financing indicators Country Transition Category GNI per Capita (USD) Total Fertility Rate Modern Contraceptive Prevalence Rate Percent Unmet Contraceptive Need Share of HIV Spend- ing from Donors Share of Immunization Spending from Donors Donor Expenditure on FP per WRA (USD) DAH as % Current Total Health Expenditure Source: World Bank, Atlas Method (2017) World Bank (2017) FP2020 Annual Report (2018) & World Bank (since 2012) FP2020 Annual Report (retrieved 2019; various years) UNAIDS GAM (retrieved 2019) WHO Immunization Financing (2017) IHME (2017); UN World Population Prospects (2015) WHO GHED (2016) Long-term, low-priority transition 680 (280–2100) 4.70 (2.87–7.18) 19.80% (2.74–46.60%) 28.10% (18.30–39.80%) 90.5% (41.3–100.0%) 76.4% (24.0–99.0%) 1.21 (0.02–8.37) 26.1% (5.1–53.8%) Medium-term, higher-risk transition 1525 (800–3570) 3.23 (1.95–5.62) 31.79% (2.74–65.50%) 24.95% (9.90–36.92%) 81.2% (39.1–95.6%) 73.2% (1.0–89.0%) 0.73 (0.00–4.01) 13.3% (1.2–42.5%) Short- to medium-term, lower-risk transition 3540 (1790– 5430) 2.34 (1.23–4.31) 45.51% (25.75–68.00%) 18.72% (8.54 5.30%) 46.1% (1.8–95.7%) 6.0% (0.0–94.0%) 0.03 (0.00–3.58) 1.7% (0.0–5.7%) While we believe these categories are useful in focusing attention on the countries that are most likely to tran- sition in the coming years and those with the weakest capacity to address transition risks, it is still necessary to examine each country’s characteristics individually to identify the specific risks and challenges associated with FP transition in the short- and long-terms. The data for this global landscape were drawn from publicly available sources including the World Bank, FP2020, WHO, IHME, and UNAIDS. Each organization utilizes different data collection techniques, ranging from country self-reporting to estimation analyses derived from a variety of sources. There are inherent limitations to each reporting method. While reliable data sources for FP program indicators, such as mCPR and method mix availability, have increased due to FP2020/Track20 and other FP M&E initiatives, verified, comprehensive information about FP expenditures is not widely avail- able. For example, only 32 countries self-report annu- al domestic FP spending to the WHO National Health Accounts program, and, at the time of writing, an esti- mation of out-of-pocket FP expenditures had only been conducted for four Family Planning Spending Assess- ment (FPSA) nations: Kenya, Bangladesh, Indonesia, and Senegal. A current breakdown of FP expenditures by commodities, service provision, and other activities is generally not available except in FPSA countries. This lack of financial data in the FP sector stands in contrast with the rigorous country-level financial M&E in HIV and immunization programs via the National AIDS Spending Assessments (NASAs) and required annual progress reports for Gavi. Existing FP expenditure assessments beyond FPSAs, such as the CHAI-RHSC FP Market Reports, present detailed but highly aggregated data that is not sufficient for in-depth country analyses. Transitions in Family Planning | 26 TABLE 3.2: Family planning and health financing indicators for countries in the long-term, low-priority transition category GNI per Capita (USD) Total Fertility Rate Modern Contraceptive Prevalence Rate Percent Unmet Contraceptive Need Share of HIV Spending from Donors Share of Immunization Spending from Donors DAH as % Current Total Health Expen- diture Donor Expendi- ture on Family Planning per WRA (USD) Country Source: World Bank, Atlas Method (2017) World Bank (2017) FP2020 Annual Report (2018) & World Bank (since 2012) FP2020 Annual Report (retrieved 2019; various years) UNAIDS GAM (retrieved 2019) WHO Immunization Financing (2017) WHO GHED (2016) IHME (2017); UN (2015) Afghanistan* $560 4.48 19.80% 28.10% n.a. 94.0% 17.5% $1.89 Benin $800 4.91 15.38% 35.50% 71.8% 47.0% 30.5% $2.16 Burkina Faso $590 5.27 22.80% 26.70% 70.5% 72.0% 23.5% $0.83 Burundi $280 5.62 16.60% 32.96% 87.0% 89.0% 33.8% $1.25 Cameroon $1370 4.64 24.60% 32.80% 60.6% 68.0% 9.3% $0.74 Central African Republic $390 4.80 17.84% 28.80% 88.0% 94.2% 40.9% $0.06 Chad $640 5.85 5.66% 24.60% 73.1% 76.9% 14.6% $0.19 Comoros $1280 4.28 13.38% 35.73% 91.6% 92.6% 10.8% $3.94 Cote d’Ivoire $1580 4.85 22.72% 29.30% 86.6% 73.0% 15.0% $0.82 DRC* $460 6.02 11.01% 39.80% 42.7% 99.0% 43.4% $2.91 Eritrea n.a 4.06 7.12% 30.23% 91.1% 87.0% 11.7% $0.02 Ethiopia* $740 4.08 26.88% 23.90% 84.5% 59.0% 15.3% $3.67 Gambia $680 5.36 8.14% 26.17% n.a. 72.0% 43.8% $0.03 Guinea $790 4.78 10.96% 24.70% 92.0% n.a. 27.2% $8.37 Guinea-Bissau $660 4.56 29.70% 21.89% 88.4% 71.0% 20.3% $0.11 Haiti* $760 2.87 22.85% 38.64% 96.4% 98.0% 38.4% $2.25 Liberia* $620 4.51 33.77% 28.24% 99.4% 85.0% 30.1% $3.00 Madagascar* $400 4.13 34.80% 25.20% 41.3% 79.0% 25.1% $1.21 * USAID FP Priority Country | See Annex 3 for the Color-Coding Classification Scheme  long-term, low-priority transition range |   medium-term, higher-risk transition range  short- to medium-term, lower-risk transition range Pharos Global Health Advisors | 27 GNI per Capita (USD) Total Fertility Rate Modern Contraceptive Prevalence Rate Percent Unmet Contraceptive Need Share of HIV Spending from Donors Share of Immunization Spending from Donors DAH as % Current Total Health Expenditure Donor Expenditure on Family Planning per WRA (USD) Country Source: World Bank, Atlas Method (2017) World Bank (2017) FP2020 Annual Report (2018) & World Bank (since 2012) FP2020 Annual Report (retrieved 2019; various years) UNAIDS GAM (retrieved 2019) WHO Immunization Financing (2017) WHO GHED (2016) IHME (2017); UN (2015) Malawi* $320 4.51 46.60% 18.30% 97.4% 94.0% 53.8% $5.21 Mali* $770 5.97 13.48% 26.80% 100.0% 84.0% 32.7% $3.23 Mauritania $1100 4.61 9.76% 32.10% 100.0% 54.0% 8.2% $0.46 Mozambique* $420 5.18 32.55% 26.00% 97.4% 72.0% 38.1% $3.42 Niger $360 7.18 15.62% 19.80% 99.2% 68.0% 13.0% $1.02 Nigeria* $2100 5.46 13.82% 24.80% 88.7% 76.0% 9.8% $0.87 Rwanda* $720 3.81 30.02% 22.70% 90.9% 85.0% 50.6% $1.85 Sao Tome and Principe $1770 4.39 32.60% 32.02% 92.5% 35.0% 44.6% $0.09 Senegal* $1240 4.70 18.76% 25.30% 74.0% 24.0% 6.1% $4.28 Sierra Leone $510 4.36 24.79% 26.76% 99.0% 93.0% 41.0% $0.76 Somalia n.a. 6.17 14.23% 29.41% 100.0% n.a. n.a. $0.22 South Sudan* n.a. 4.77 2.74% 30.80% 90.5% 86.7% n.a. $1.62 Tajikistan $990 3.31 20.81% 24.68% 92.0% 68.1% 5.1% $0.69 Timor-Leste $1790 5.39 15.56% 27.62% 98.8% 77.0% 31.6% $4.07 Togo $610 4.38 23.31% 34.40% 79.9% 44.0% 20.7% $0.06 Uganda* $600 5.50 27.54% 32.60% 87.0% 65.0% 40.4% $3.59 Yemen* n.a. 3.89 20.43% 32.30% 71.0% n.a. n.a. $0.75 AVERAGE (unweighted) $835 4.82 20.19% 28.56% 85.6% 74.5% 26.5% $1.88 * USAID FP Priority Country | See Annex 3 for the Color-Coding Classification Scheme TABLE 3.2 (continued): Family planning and health financing indicators for countries in the long-term, low-priority transition category  long-term, low-priority transition range |   medium-term, higher-risk transition range  short- to medium-term, lower-risk transition range Transitions in Family Planning | 28 • Chapter 3: Global Landscape of Family Planning Transitions Countries with Long-Term, Low-Priority Transition Thirty-five countries in this category (see Table 3.2) are not likely to transition in FP in the coming decade, and some may not transition for several decades or longer. Their low incomes, large unmet need for contraception, and limited domestic financing allocated to FP suggests that they will remain heavily dependent on donor aid in the coming two decades. In general, these countries have a GNI per capita of less than $1000, a total fertility rate (TFR) of greater than 4 children per woman, and a modern contraceptive prevalence rate (mCPR) of less than 25%. Unmet contraceptive need exceeds 30%. Thirty of the 35 countries are in sub-Saharan Africa, with two from Central Asia and one each from the Caribbean, the Pacific, and the Middle East. Graduation from Glob- al Fund assistance for HIV and from the Gavi immuni- zation program is generally not anticipated until after 2040, as most of the funding for key health programs in HIV/AIDS, tuberculosis, malaria, and immunization stems from donor aid. However, some of these coun- tries may still find it hard to cope with even a leveling off or reduction in donor support, especially if their national budgets do not prioritize basic health services, because of population momentum: as an increasing number of individuals enter reproductive age, unmet need is antici- pated to grow rapidly. These countries which are unlikely to transition are a priority for global family planning initiatives such as FP2020 because they represent the highest level of both financial and contraceptive need. Their average fertility rate of 4.8 translates to high maternal mortali- ty ratios that could be mitigated by increased modern contraceptive coverage. These countries rely heavily on donor assistance for health, with DAH accounting for an average of 42.5% of total health expenditure. There is no clear trend in domestic policies related to FP within this category: some countries score high on the Family Plan- ning Policy Effort index, such as Ethiopia, while its neigh- bor, South Sudan, does not. This result suggests that sociocultural norms and political economies specific to each national and subnational context can dictate the level of public and political commitment to FP initiatives. Countries in this long-term, low-priority transition cate- gory are not anticipated to undergo transitions in other major health areas in the near future. Only eight out of the 35 nations are expected to graduate from the Gavi immunization program before 2040.77 Additionally, none of the countries in this category is expected to graduate from Global Fund assistance for HIV/AIDS until 2041 or later.78 Expenditures for HIV, TB, malaria, and immuni- zation are high, and funds overwhelmingly come from donors, not from national governments. Burundi and Haiti are good examples of low-likelihood, low-priority FP transition countries. Burundi has a GNI per capita of $280 and one of the highest TFRs in the world at 5.62, and its mCPR of 16.6% is among the lowest. Nearly 33% of WRA in the country would like to avoid pregnancy but are not currently using modern contraceptives, and the maternal mortality ratio is 712 per 100,000 live births. Burundi is also heavily depen- dent on donor aid in HIV and immunization; the coun- try is not anticipated to graduate from Gavi or GF HIV assistance until after 2040. Because of these significant FP outcome and funding challenges in Burundi, contin- ued donor involvement in FP programming for the near future is needed to improve FP indicators prior to initiat- ing transition. Haiti has a much lower TFR of 2.87, but its low GNI per capita ($760), low mCPR (22.85%) and high unmet contraceptive need (38.64%) situate the country firmly within the in the low transition likelihood group. Haiti depends heavily on foreign assistance for health; its graduations from Gavi and the Global Fund HIV program are not expected until after 2040, and DAH accounts for over 85% of expenditures in the key disease areas of HIV, TB, malaria, and immunization. Continued external funding over the long-term will be required to sustain Haiti’s FP programming. 77 Silverman, R. (2018). Projected health financing transitions: timeline and magnitude. Center for Global Development Working Paper. 78 Ibid. Pharos Global Health Advisors | 29 • Chapter 3: Global Landscape of Family Planning Transitions Nations in this category are many years away from transition in FP and other health areas, but incremen- tal transfer of responsibility for FP activities could be prudent so that eventual simultaneous graduations in numerous major disease programs do not overwhelm domestic institutional and financial capacity and result in poor outcomes for FP programs. Additionally, if domestic policies in key donor countries result in unex- pected, significant decreases in the amount of available FP funding, this group of countries—which is more reli- ant on external resources—will be disproportionately affected. Early and gradual transition planning in these countries can mitigate the possible risk of donor funding volatility for FP and SRH. Countries with Short- to Medium-Term, Lower-Risk Transition The 23 middle-income countries in this category (see Table 3.3) should be generally well-positioned to tran- sition from donor assistance for FP in the short- to medium-term because of their relatively high national incomes, limited donor dependence in the health sector, and more advanced status in achieving FP goals. Over- all, these nations are more affluent, with an average GNI per capita of over $3600. Their geographic distribution is varied: most are in the MENA, LAC, or ECA regions, with smaller representation from South Asia, East Asia, and Africa. They typically have a TFR less than 3, an mCPR of 40% or greater, and unmet contraceptive need of less than 20%. Because of their higher national incomes, they are either ineligible for Gavi assistance or are transitioning from Gavi within the next five years, and only six of the 23 countries are projected to be receiving support from the Global Fund for HIV past 2030. DAH accounts for an average of only 2% of total health expenditure for these countries. A few of the countries remain dependent on donor aid in specific disease areas, such as Ukraine (77% of HIV spending from donors) and Indonesia (57% of TB spending from donors). However, national govern- ments in these countries contribute a large majority of the financing for HIV, TB, malaria, and immunization programs. FP transitions in this shorter-term, lower-risk transition category can be expected to occur relatively smoothly in large part because these countries have greater finan- cial capacity to absorb FP program costs. Their depen- dence on outside funding for FP is low: currently only six of the 23 countries receive more than $1M in DAH annu- ally for FP. Even when the donor funding is larger, it only represents a very small fraction of national FP spending. In India, for example, FP donor assistance of $24.6M annually amounts to less than 10% of domestic public spending for family planning.79 Because these countries already fund and implement most of their FP activities, reduced donor support and exit should be relatively less difficult, though not necessarily challenge-free. 79 IHME DAH database, 2017; FP2020 Annual Report, 2018. Transitions in Family Planning | 30 TABLE 3.3: Family planning and health financing indicators for countries in the short- to medium-term, lower-risk transition category GNI per Capita (USD) Total Fertility Rate Modern Contra- ceptive Preva- lence Rate Percent Unmet Contraceptive Need Share of HIV Spending from Donors Share of Immunization Spending from Donors DAH as % Current Total Health Expen- diture Donor Expendi- ture on Family Planning per WRA (USD) Country Source: World Bank, Atlas Method (2017) World Bank (2017) FP2020 Annual Report (2018) & World Bank (since 2012) FP2020 Annual Report (retrieved 2019; various years) UNAIDS GAM (retrieved 2019) WHO Immunization Financing (2017) WHO GHED (2016) IHME (2017); UN (2015) Algeria $3940 2.71 50.00% n.a. 1.8% 0.0% 0.0% $0.00 Armenia $3990 1.60 28.00% n.a. 56.0% 5.8% 1.7% $0.66 Azerbaijan $4080 1.90 n.a. n.a. 31.1% 22.0% 0.4% $0.00 Bhutan $2660 2.02 47.36% 11.67% n.a. 94.0% 4.8% $0.02 Bolivia $3130 2.84 32.43% 35.30% 41.4% 6.0% 3.2% $0.04 Egypt $3010 3.21 41.37% 14.02% 48.9% 0.0% 1.0% $0.05 El Salvador** $3560 2.06 68.00% n.a. 14.3% 18.9% 2.3% $0.03 Georgia $3770 1.99 n.a. n.a. 30.6% 3.0% 2.3% $0.02 Guatemala $4060 2.92 48.90% n.a. 30.6% 0.0% 0.9% $1.93 Honduras $2250 2.42 44.17% 18.43% 46.9% 16.0% 3.1% $0.28 India* $1790 2.30 40.01% 19.00% n.a. 64.0% 1.0% $0.07 Indonesia** $3540 2.34 45.51% 13.90% 57.6% 12.0% 0.4% $0.06 Iraq $4630 4.31 26.90% 26.11% n.a. n.a. 0.4% $0.00 Jordan $3980 3.31 37.40% n.a. 7.4% 0.0% 5.7% $3.58 Moldova $2200 1.23 41.70% n.a. 61.1% 26.0% 3.7% n.a. Mongolia $3270 2.71 40.31% 19.97% 40.8% 7.0% 3.9% $0.00 Morocco** $2860 2.45 58.00% n.a. 49.5% n.a. 0.7% $0.03 Nicaragua** $2130 2.17 52.88% 8.54% 56.5% 26.0% 4.6% $0.07 Philippines* $3660 2.89 25.75% 30.90% 56.0% 0.0% 2.2% $0.43 South Africa** $5430 2.43 47.03% 14.98% 23.5% n.a. 1.9% $0.04 Sri Lanka** $3850 2.03 50.13% 19.50% 45.3% n.a. 0.9% $0.00 Tunisia** $3490 2.18 50.90% n.a. 95.7% 2.0% 0.1% $0.00 Ukraine $2390 1.37 47.80% n.a. 77.0% 0.0% 0.8% $0.00 AVERAGE (unweighted) $3377 2.41 44.03% 19.36% 43.6% 16.0% 2.0% $0.32 * USAID FP Priority Country | ** USAID FP Graduated Country  long-term, low-priority transition range |   medium-term, higher-risk transition range |   short- to medium-term, lower-risk transition range Pharos Global Health Advisors | 31 • Chapter 3: Global Landscape of Family Planning Transitions The nations in this category are likely to experience simultaneous health graduations in the upcoming years, but they are more able to leverage domestic resources to close the comparatively narrow funding gap left by donor withdrawal. El Salvador (2017 GNI per capita of $3560) is an exam- ple nation within this category. It has already graduated from USAID FP assistance,80 and the country’s TFR of 2.06 and mCPR of 68.0% are impressive. According to IHME, El Salvador received only $45,000 of DAH for FP in 2017, and DAH as a percentage of total health expen- diture is a relatively low 2.3%. However, there may still be challenges to sustaining FP programs in some of these countries, particularly those that struggle to address inequities in contraceptive coverage and quality and those that rely significantly on donor aid for other disease programs. The Philip- pines, for example, has an mCPR of 25.75% and over 30% unmet contraceptive need. Over half of the nation’s expenditures on HIV and TB come from the donor aid, and transition from the Global Fund is expected within a decade. While DAH accounts for only 2.2% of overall Philippine health expenditures, the additional financial strain of HIV transition, coupled with the historical influ- ence of religion upon the national FP political economy, may preclude adequate government resource mobili- zation to address the low mCPR and satisfy unmet FP need. In this case, out-of-pocket expenditures for FP could rise, exacerbating inequity of access to contra- ceptives by socioeconomic status. Easy transition with sustained FP program results is not guaranteed for all countries in this category. The erosion of past gains due to financial, procurement, or policy/ political factors could occur in some of these nations and might merit targeted analysis and focused action to avoid backsliding. Countries with Medium-Term, High-Risk Transition The 22 LMIC countries in this category (see Table 3.4) need to be most vigilant about FP transition, since grad- ual declines in FP donor funding may start soon, with full transition possible in the medium term (upcoming 5-10 years), and domestic capacity to fund and sustain family planning is at serious risk. In general, these 22 countries have intermediate incomes, with GNI per capita between $1000 and $3000. They typically have a TFR between 3 and 4, an mCPR between 25% and 55%, and unmet contraceptive need between 20% and 30%. Transition from Gavi is anticipat- ed between 2025 and 2040, and from Global Fund HIV assistance between 2030 and 2040. Most countries in this group remain heavily dependent on donors to fund HIV, TB, malaria, and immunization programs, but some have already assumed responsibility for at least a third of expenditures in two or more disease areas. Most of the nations in this category are FP2020 focus countries because their average mCPR (32.9%) remains low, and they have significant unmet contraceptive need. However, because of their higher national incomes, they have greater capacity to take on financial responsibility for health programming. This point is reinforced by the shorter timelines for transition in immunization; all but one of the 22 countries are expected to graduate from Gavi prior to 2040, and most within the next decade.81 80 See: https://www.usaid.gov/global-health/health-areas/family-planning/countries#graduated 81 Silverman (2018). https://www.usaid.gov/global-health/health-areas/family-planning/countries#graduated Transitions in Family Planning | 32 TABLE 3.4: Family planning and health financing indicators for countries in the medium-term, higher-risk transition category GNI per Capita (USD) Total Fertility Rate Modern Contra- ceptive Prevalence Rate Percent Unmet Contraceptive Need Share of HIV Spending from Donors Share of Immuniza- tion Spending from Donors DAH as % Current Total Health Expen- diture Donor Expenditure on Family Planning per WRA (USD) Country Source: World Bank, Atlas Method (2017) World Bank (2017) FP2020 Annual Report (2018) & World Bank (since 2012) FP2020 Annual Report (retrieved 2019; various years) UNAIDS GAM (retrieved 2019) WHO Immunization Financing (2017) WHO GHED (2016) IHME (2017); UN (2015) Angola $3570 5.62 12.50% n.a. 83.6% n.a. 3.6% $0.91 Bangladesh* $1470 2.08 45.50% 19.10% 95.6% 73.0% 7.6% $0.75 Cambodia $1230 2.53 30.07% 28.04% 95.3% 77.0% 18.9% $0.74 Congo $1430 4.60 26.20% 36.92% 50.8% 80.0% 3.3% $0.02 Djibouti $1880 2.79 19.03% 30.02% 90.5% 59.3% 27.8% $1.87 eSwatini** $2950 3.03 65.50% n.a. 65.8% 7.0% 13.8% $3.03 Ghana* $1880 3.93 22.08% 33.60% 62.6% 65.0% 12.8% $1.37 Kenya* $1460 3.79 42.74% 20.30% 63.1% n.a. 19.5% $4.01 Kyrgyz Republic $1130 3.00 28.23% 20.10% 87.1% 73.3% 3.3% $0.00 Laos $2270 2.64 36.46% 22.90% 87.7% 68.0% 18.1% $0.00 Lesotho $1210 3.04 50.44% 16.50% 57.6% 80.3% 17.3% $0.08 Myanmar $1210 2.19 32.35% 16.23% 85.0% n.a. 5.9% $0.02 Nepal* $800 2.08 38.09% 27.60% 81.9% 73.0% 11.7% $1.20 Pakistan* $1580 3.41 20.80% 29.30% 63.7% 82.0% 4.1% $0.71 Papua New Guinea $2340 3.61 19.66% 31.42% 80.6% 89.0% 22.1% $0.15 Solomon Islands $1920 3.80 16.97% 30.45% 83.3% 56.0% 26.2% $0.67 Sudan $2380 4.47 2.74% 30.80% 65.4% 81.0% 2.2% $0.17 Tanzania* $920 4.95 31.24% 26.90% 54.7% n.a. 36.4% $3.13 Uzbekistan $2000 2.46 46.89% 12.29% 39.1% 1.0% 1.2% $0.00 Vietnam $2160 1.95 48.42% 19.05% 68.2% 9.0% 2.3% $0.01 Zambia* $1290 4.93 35.84% 23.00% 93.3% 80.8% 42.5% $1.91 Zimbabwe $1170 3.68 51.61% 9.90% 86.4% 77.0% 25.4% $1.03 AVERAGE (unweighted) $1739 3.39 32.88% 24.22% 74.6% 62.9% 14.8% $0.99 * USAID FP Priority Country | ** USAID FP Graduated Country  long-term, low-priority transition range |   medium-term, higher-risk transition range |   short- to medium-term, lower-risk transition range Pharos Global Health Advisors | 33 • Chapter 3: Global Landscape of Family Planning Transitions Many countries in this category are already in the prepa- ratory or accelerated transition phase within the Gavi graduation program, paying a significant portion of over- all immunization expenditures with domestic resources. For example, the Vietnam government contributed 91% of all immunization expenditures in 2017 and is expect- ed to become fully self-financing in immunization by 2020. Meanwhile, other nations in this category, such as Papua New Guinea and Sudan, relied on donor support for over 80% of immunization spending in 2017 despite anticipated Gavi transitions by 2025. Six of the 22 medi- um-term, higher-risk FP transition countries are project- ed to transition from the Global Fund for HIV before 2040,82 and most of them will likely experience steady declines in Global Fund support in the years leading up to full transition. Nine countries in this group finance at least one-third of total HIV expenditures with domes- tic resources, and 14 finance at least one-third of total malaria expenditures with domestic funding. Health and family planning transitions over the coming decade for nations in this category will place a significant financial burden on national governments. While DAH only accounts for an average of 14.8% of total health expenditures in the 22 nations, most are still dependent on donor funding in the areas of HIV, TB, malaria, and immunization. In addition, as the three country case studies illustrate, these countries also face other prob- lems and constraints – such as weak national procure- ment systems, low capacity to set priorities in health, policies and laws that inhibit access to FP services, and limited political support for family planning – that create a high risk to successful and sustained FP transition. Ghana, Kenya, and Bangladesh are three countries with- in this medium-term, higher-risk country cohort that have been selected for in-depth analysis in case studies. Ghana (2017 GNI per capita of $1880) relies heavily on foreign aid for major infectious disease programs, with DAH comprising over 65% of expenditures in HIV, TB, and immunization. Although Ghana’s National Health Insurance Scheme (NHIS) provides coverage for many health services and products, the system is significantly underfunded and slow to reimburse providers. Conse- quently, out-of-pocket expenditures account for nearly 40% of total health expenditure in Ghana, exacerbating inequality in access to health services by socioeconom- ic status. Ghana is facing imminent transition from Gavi, and the Global Fund has begun to assess the country’s preparedness for increased domestic contribution to nations HIV, TB, and malaria programs.83 Ghana’s family planning indicators remain low, with 22% mCPR and 33.6% unmet contraceptive need. High out-of-pocket FP spending and inconsistent supply of FP commodities contribute to these poor indicators. According to a 2012 National Health Insurance Author- ity act, family planning packages should be covered by NHIS, but this “guarantee” is not implemented in prac- tice. One donor (DFID) has already withdrawn from direct family planning activities in Ghana, and it intends to conclude all HSS initiatives in Ghana entirely by 2022. The medium-term stances of other donors (notably USAID and UNFPA) are uncertain; though these orga- nizations do not plan to transition from FP in Ghana in the near-term, U.S. and international funding challenges may constrain future FP activities. Much needs to be done to prepare Ghana for possible declines in external support for FP, especially as the national family plan- ning program is likely to need additional financing in order to meet national and international FP goals. The case study in this report analyzes these challenges and examines options for enhancing Ghana’s readiness to face FP transition in the context of other health transi- tions and reforms of the national health financing and delivery system. 82 Silverman (2018). 83  MoH and Oxford Policy Management, 2018. A roadmap for sustainability and transition from external finance: mapping donor and domestic financing for the health sector in Ghana and planning for the future. Transitions in Family Planning | 34 • Chapter 3: Global Landscape of Family Planning Transitions Kenya (2017 GNI per capita of $1,460) experienced considerable gains in its FP program outcomes from the mid-2000s to the early 2010s. However, govern- mental devolution in 2013 placed most health financing responsibility at the county level, resulting in a reduction of political commitment to financing and stewarding FP programs along with a regression of FP indicators. The relatively high national mCPR of 42.7% masks signifi- cant regional variation in contraceptive use, and unmet need stands at 20.3%. In FY2016, approximately 75% of FP funding in Kenya came from donors, and the major- ity of domestic funds for FP were directed towards health worker salaries. Limited domestic financing of the FP program, particularly FP commodities, has led to a looming crisis of contraceptive stock-outs across the nation. Key FP donors in Kenya, including USAID, DFID, and the Gates Foundation, are in the process of negoti- ating a commodity co-financing plan with the Kenyan government to increase domestic FP funding commit- ments and avert the stock-out crisis. Kenya also relies on donor assistance in other major health programs. External funds accounted for 63% of all HIV expenditures and 53% of all malaria expenditures in 2016. Transition from Global Fund assistance is not anticipated until after 2041 due to high HIV, TB, and malaria disease burdens, but full transition from Gavi is expected by 2024 based upon Kenya’s increasing national income.84 PEPFAR, a key HIV donor in Kenya, is also contemplating a decline in financial assistance in the near term.85 As health accounts for only 7-8% of Kenya’s budgetary spending, the country does not currently have the fiscal space to efficiently fund the financial gaps left by exiting donors. High-cost donor- backed health programs are only partially included in the National Hospital Insurance Fund (NHIF); for exam- ple, malaria treatment is covered, but HIV care is not, largely due to the expense of ARTs. While FP services are technically covered, consumer and provider under- standing of FP inclusion in NHIF is limited. Kenya plans to adopt a UHC scheme that is currently not designed or adequately funded to absorb the costs of major health programs, including HIV and FP, as donors transition from the country. Kenya faces significant challenges in health financing, priority-setting, and governance that place the country’s already-tenuous FP program at serious risk as transition approaches. This case study assesses these risks of transition and examines options for improving Kenya’s preparedness for FP transition in the context of other health transitions and reforms of the national health financing system. Bangladesh (2017 GNI per capita of $1,470) is the most advanced of the three case study countries in its FP tran- sition status. Due to strong, high-level political commit- ment to lowering national fertility, the country’s FP program has witnessed great success since its inception in the 1970s. Fertility rates have dropped to near-replace- ment levels, and mCPR stands at 45% (married women), with unmet need at 19%. Bangladesh exceeds the USAID TFR threshold for graduation and is approaching the mCPR threshold; for this reason, USAID expects to grad- uate Bangladesh from FP assistance in the next decade or sooner.86 Similarly, DFID and UNFPA funding for FP in Bangladesh is only assured through 2022; addition- al funding past that year is uncertain.87 Though donors are only minimally involved in financing and procuring FP commodities in Bangladesh—the government funds 96% of FP commodities—external resources are still the primary source of funding for important complementary FP activities such as behavioral change communication, FP research and surveys, quality assurance, monitoring and evaluation, and outreach to key vulnerable popula- tions, particularly married adolescents and the poor. Careful transition planning involving all FP stakeholders is necessary to ensure that these essential enabling envi- ronment activities are properly transferred to the nation- al government prior to upcoming FP donor withdrawal. 84 Silverman (2018). 85 In-country informant. 86 In-country informant. 87 In-country informant. Pharos Global Health Advisors | 35 • Chapter 3: Global Landscape of Family Planning Transitions In comparison to FP, other major health programs in Bangladesh are not as well-positioned for transition. Donor resources accounted for 96% of HIV spending, 84% of TB spending, 77% of malaria spending, and 73% of immunization spending in 2017-18. Though tran- sition for HIV, TB, and malaria are not expected in the next decade, Bangladesh’s co-financing requirements to the Global Fund will increase as its national econ- omy grows. Moreover, Gavi is actively preparing for immunization transition in Bangladesh, and it plans to withdraw from the country entirely by 2026. The fiscal space for health in Bangladesh is exceedingly narrow; the Bangladesh health budget accounts for only 5% of the total national budget and less than 1% of GDP. As Bangladesh’s domestic financing responsibilities for major infectious disease programs accumulate, and as the country attempts to address heavy reliance on OOP payments in the health sector through the adoption of a UHC scheme, adequate financial resources for the FP program—especially enabling environment activities— may no longer be available. Despite these challenges, informants were unaware of any ongoing transition planning in FP or the health sector generally. Bangladesh faces difficult upcoming transitions in its infectious disease programs that will put addition- al pressures on the already-limited national health budget. Though the FP program’s basic contraceptive procurement and supply functions should experience a relatively smooth transition, the fiscal and managerial requirements of other health transitions may jeopardize FP enabling environment activities that are essential to sustaining and improving upon the program’s histor- ic success. This case study assesses these transition risks and proposes options for bolstering Bangladesh’s readiness for FP transition in the context of the coun- try’s other financing and capacity challenges in the health sector. Transitions in Family Planning | 36 Executive Summary Ghana has the ambition to become self-reliant from aid, but the country has not developed concrete strategies to achieve this goal in health and specifically in family planning (FP). This situation exists despite declining aid and funding gaps in key health areas such as FP and HIV. Within the Ghanaian context, FP is not central to the national development agenda, nor are the explicit contri- butions of FP to other Sustainable Development Goals (SDGs) defined. The current Ghana National Develop- ment Plan does not mention reproductive health or rights and, while there are a few strong female advo- cates for FP within government, they alone have not generated sufficient political will on this issue. Ghana’s modern contraceptive prevalence rate (mCPR) has not accelerated relative to other sub-Saharan Afri- can countries nor in accordance with its LMIC status. Its FP performance lags behind other countries such as Kenya and Bangladesh. The country continues to have high levels of unmet need, estimated at 33.6%, which exceeds the mCPR of 22.1% (all women). While some indicators of FP access have improved, such as a reduc- tion in rural-urban disparities in access and use of FP in some regions of the country, there remain many missed opportunities such as post-partum FP, and areas of concentrated need, both geographically and within sub-populations such as adolescents. Current FP programming in Ghana remains highly donor dependent. While Ghana’s FP2020 commitments call for greater domestic resource allocation for FP, in practice, these funds have not materialized as expected, nor are they adequately tracked using FP expenditure surveys.88 The Government of Ghana (GoG) finances only 10% of FP commodity resources (mainly in the form of warehousing and personnel costs) while donors funded all contraceptive commodities in Ghana for the period 2016-2018.89 Furthermore, any additional GoG contributions to other FP program activities are not documented.90 Donor contributions for FP are current- ly sourced from two main partners, UNFPA and USAID, which provide almost all commodity financing for the country. Additionally, Ghana relies on external partners for FP commodity procurement, supply chain manage- ment, and technical assistance for activities such as data analysis, thus increasing its vulnerability to a rapid transition away from donor aid. While government and donor officials interviewed for this case study were aware of the possibility of FP tran- sition, most had not considered the potential risks and challenges of transition. The leading FP donors—USAID and UNFPA—do not appear to be contemplating full exit from Ghana’s FP program in the next few years, but gradual declines in FP funding alongside decreasing external resources for other health programs in Ghana could put pressure on domestic resources to fill a wider FP funding gap.91 No formal FP sustainability and transi- tion planning has begun, putting FP behind other nation- al priority health programs in this regard. Chapter 4: Ghana Country Case Study 88 Ghana government and partner respondent interviews. 89 In-country respondent. It is likely that this has been the case for longer, however, data was only availed for this timeframe. 90  MoH and Oxford Policy Management, 2018. A roadmap for sustainability and transition from external finance: mapping donor and domestic financing for the health sector in Ghana and planning for the future. 91 Partner respondent interviews. Pharos Global Health Advisors | 37 • Chapter 4: Ghana Country Case Study Alongside FP program transition, the country also faces fiscal pressures due to other health program funding requirements. In 2017, Ghana was responsible for a total of US $144 million in co-financing payments to support immunization, HIV/AIDS, TB, and malaria programs backed by Gavi, Global Fund, and PEPFAR. As Ghana’s health financing capacity matures, its co-financing obli- gations are also expected to increase, reaching US $350 million in 2025, approximately half of the total Ministry of Health budget (including donor funds) and 70% of all domestic government funds for health in 2016.92,93 Whereas in the past, co-financing requirements for some priority health programs such as HIV and TB were loosely interpreted, compliance has become more rigorously measured in recent years by donors, and the consequences of defaulting include the loss of significant donor grant awards. Moreover, as Ghana approaches the formal five-year accelerated transition period with Gavi in 2021, its co-financing requirements will keep increasing. FP donors do not have similar formal arrangements for domestic co-financing, nor do they have any recourse if the GoG does not offer expect- ed contributions.94 This situation creates a serious risk for FP if Ghana fulfills its co-financing commitments to the HIV/TB/malaria and immunization donors by prior- itizing funding for these other programs over FP. Addi- tionally, if FP donors later ask Ghana to pay for a larger share of FP costs, the country may be ill-prepared to do so, both fiscally and in terms of political support for FP. Many health programs are vying for inclusion within Ghana’s National Health Insurance Scheme (NHIS) essential benefits package, which includes tertiary, secondary, and primary care, as a key transition and financial sustainability strategy. For FP, an NHIS pilot project is ongoing to assess the feasibility of including clinical FP service using a case-based payment system; early positive results have emerged. At the same time, funding for FP in the NHIS is at risk of being crowd- ed out by other priority programs, particularly HIV. As one interviewee stated, “These huge disease areas with high expenditures will eat [the NHIS] up.” While FP and other vertical health programs are under consideration for integration into the NHIS, the government may also look for ways to reduce inefficiencies found within these programs and demand greater accountability for spend- ing and performance. This context creates a difficult environment for FP program transition in Ghana. The present case study examines the risks and challenges associated with FP transition and identifies key opportunities and areas of improvement for both donors and the national govern- ment. This report begins with an introduction to Ghana’s current FP program and health financing status. It then examines in-depth the four key components of our FP transition framework: financing for FP and other health programs; procurement and supply chain; tech- nical capacity; and enabling factors, including political commitment and legal & human rights. We conclude the case study by offering specific risks and key options for consideration to prepare Ghana for eventual transi- tion in FP alongside simultaneous transitions in other health programs. 92  MoH and Oxford Policy Management, 2018. A roadmap for sustainability and transition from external finance: mapping donor and domestic financing for the health sector in Ghana and planning for the future. 93  Ghana MoH, 2018. Medium term expenditure framework for 2018-2021. https://www.mofep.gov.gh/sites/default/files/pbb-estimates/2018/ 2018-PBB-MoH.pdf 94  See also: Silverman, R., & Glassman, A. (2016). Aligning to 2020: How the FP2020 core partners can work better together. Final report of the Working Group on Alignment in Family Planning. https://www.mofep.gov.gh/sites/default/files/pbb-estimates/2018/2018-PBB-MoH.pdf https://www.mofep.gov.gh/sites/default/files/pbb-estimates/2018/2018-PBB-MoH.pdf Transitions in Family Planning | 38 • Chapter 4: Ghana Country Case Study Introduction Country Context Ghana has the ambition to become self-reliant from aid, but the country has not developed concrete strategies to achieve this goal in health. To transition from heavy reli- ance on aid, in health and other sectors, the government has adopted the “Ghana Beyond Aid” charter and strat- egy. However, as government respondents acknowl- edged, there is no clear plan for operationalizing the strategy, and it is described as more of a “philosophy.” This lack of attention to or planning for health transition persists despite declining aid and funding gaps in key health areas such as FP and HIV. Through the course of this case study, no donor or government working group focusing on self-reliance and priority health program transitions in health was identified. FP is not central to the national development agenda nor is it politically championed. Government respon- dents indicated that Ghana’s strategy for transition to middle-income status is focused on developing economic sectors such as agriculture, mining and manufacturing, the benefits of which will “trickle down” to the health sector. Ghana’s 40-year development plan affirms this.95 While this plan recognizes the importance of demography in development, it assumes continued rapid population growth, expecting Ghana’s 2017 popu- lation to double to 57.3 million by 2057.96 The plan does not mention reproductive health or rights, nor does it make explicit the contribution of FP to other Sustain- able Development Goals (SDGs). While there are strong female advocates for FP within government, they alone cannot generate necessary political will. History and Performance of FP Programs in Ghana Ghana’s FP program has not accelerated relative to other sub-Saharan African countries nor in accordance with its LMIC status. In comparison to other LMICs, Ghana has high levels of unmet contraceptive need despite a long history of FP programing, which commenced in 1970, only a few years after Kenya.97 The country’s mCPR is about half of Kenya’s and its unmet need is about double. This rate of unmet need, estimated at 33.6%, has held steady in recent years, with small but not significant improvements (Box 4.1). Some govern- ment respondents suggested that these indicators might suffer from underreporting bias. Ghana’s method mix is relatively balanced with an increasing share of more effective methods. Implants account for 30.7% of the method mix, followed by short- term, injectable methods (28.5%), the pill (17.4%), other modern methods (9.7%), male condom (6.1%), female sterilization (5.3%) and IUD (2.2%). Figure 4.1 provides 2015-2020 estimates of Ghana’s method mix. These projections suggest growth in the use of long-acting reversible contraceptives (LARCs) and injectables. These methods have been traditionally provided through the public sector and financed by donors; the Ghana Demographic and Health Survey (GDHS) esti- mated that 94% of implants, 92% of female sterilization, 90% of injectables, and 84% of IUDs were obtained or performed in public sector facilities.98 Public sector provision is often done in partnership with NGO part- ners, such as Marie Stopes International (MSI).99 Total users 1,689,000 Additional users since 2012 601,000 mCPR (all women) 22.1% mCPR (MW) 29% Unmet need (MW) 33.6% Demand satisfied (MW) 46% Source: MoH/Track20 FP2020 performance (2019) BOX 4.1. FP Performance Indicators 95  Long-term National Development Plan of Ghana (2018-2057). 96  Ibid. 97  World Bank 2019, Taking stock: Financing family planning services to reach Ghana’s 2020 Goals. http://blogs.worldbank.org/africacan/taking-stock- financing-family-planning-services-to-reach-ghanas-2020-goals 98  Ghana Statistical Service (GSS), Ghana Health Service (GHS), and ICF International. 2015. Ghana Demographic and Health Survey 2014. 99  Makinen, Marty, Stephanie Sealy, Ricardo A. Bitrán, Sam Adjei, and Rodrigo Muñoz. 2011. “Private Health Sector Assessment in Ghana.” World Bank Working Paper No. 210. Washington, DC: World Bank. https://blogs.worldbank.org/africacan/taking-stock-financing-family-planning-services-to-reach-ghanas-2020-goals https://blogs.worldbank.org/africacan/taking-stock-financing-family-planning-services-to-reach-ghanas-2020-goals Pharos Global Health Advisors | 39 • Chapter 4: Ghana Country Case Study Trends in FP access have improved, but missed oppor- tunities remain. The 2015 GDHS found that more than 77.4% of women in all age groups did not discuss FP in the last 12 months when visited by a health worker or when going to a health facility.100 Post-partum FP also remains low and is estimated at 4.8% and 7% at six and twelve months, respectively.101 Trend analysis of consec- utive GDHS data sets reveals a gradual increase in the use of modern contraceptives among rural women.102 This improvement is attributed to the successes of the Community-based Health Planning Services (CHPS) and the reproductive health (RH) NGOs which “have brought health care services to the door steps of rural residents that are affordable to families and individuals.”103 These RH NGOs include MSI, Planned Parenthood Associa- tion of Ghana (PPAG), several local organizations, and the social marketing organizations GSMF International (formerly known as the Ghana Social Marketing Foun- dation) and DKT International. 100  Ghana Statistical Service (GSS), Ghana Health Service (GHS), and ICF International. 2015. Ghana Demographic and Health Survey 2014. 101  Ghana: FP2020 Core Indicator Summary Sheet: 2017-2018 Annual Progress Report. 102  Aviisah, P.A., Dery, S., Atsu, B.K., Yawson, A., Alotaibi, R.M., Rezk, H.R., and C. Guure, 2018. BMC Women’s Health. 18:141 https://doi.org/10.1186/ s12905-018-0634-9 103  Ibid. FIGURE 4.1: Ghana’s projected method mix: 2015-2020 (Source: Ghana FP CIP, 2015)  Other traditional    Rhythm  Withdrawal  Other modern methods  Cyclebeads/SDM  Lactational amenorrhea  Female condoms  Male condoms  PIlls  Injectables  Implants  IUDs  Female sterilizations 2,000,000 1,000,000 0 N um be r o f U se rs https://bmcwomenshealth.biomedcentral.com/articles/10.1186/s12905-018-0634-9 https://bmcwomenshealth.biomedcentral.com/articles/10.1186/s12905-018-0634-9 Transitions in Family Planning | 40 • Chapter 4: Ghana Country Case Study Health Financing in Ghana Ghana is one of the few LMICs to take early and seri- ous steps towards UHC. The country passed legis- lation for universal health insurance coverage – the National Health Insurance Scheme (NHIS) – in 2003. The NHIS started by covering vulnerable groups and was able to significantly expand enrollment as a result. Coverage has plateaued in recent years at about 40% of the population.104 There has also been a clear shift from supply-side financing to demand-side financing for health, using earmarked resources to support the NHIS. However, performance of Ghana’s health system is mixed. Consumer satisfaction is reportedly high, and access appears to have improved, including for the poor. However, Ghana performs worse than average on some health outcomes, including under-five, infant, and mater- nal mortality, compared to other countries at its level of income and health spending.105 While declines were realized in child mortality indicators in the mid-2000s, under five mortality fell back to its 1990 level by 2013106 and maternal mortality was declared a national emer- gency in 2008. Weak health outcomes are associated with a weak health system, low access to quality health services, as well as high unmet need for FP.107 Despite the country’s LMIC status, fiscal space for health is constrained. As a share of gross domestic product (GDP), total health expenditure (THE) is slightly below average for LMICs. The health budget constitutes less than 7% of the national budget.108 There is very limit- ed discretionary budget for health available after recur- rent costs have been allocated. The majority of Ghana’s on-budget public spending, estimated at 73%, is through the National Health Insurance Authority (NHIA).109 With- in the GHS, there is low budget execution and system inefficiencies, as evidenced by poor health outcomes relative to health investment. The government relies on donor funding for a significant portion of its health budget – an average of 20% over the past five years – with donor assistance concentrated in areas such as HIV (63% in 2016) and TB (76%).110,111,112 Most donor financing is concentrated on major infectious disease programs. While these programs (HIV, malaria, immunization) receive the lion’s share of donor funding, international contributions for health are on a downward trajectory. Figure 4.2, based on a DFID-sponsored study, estimates future donor financing for six priority health programs through 2025, with funding declining 8% per year on average, from US $248 million in 2017 to US $124 million in 2025.113 External financing is projected to decline most rapidly for FP (15% per annum), followed by HIV/AIDS (10% per annum).114 Due to DFID’s withdrawal 104  Wang, H. Otoo, N. and L. Dsane-Selby. 2017. Ghana National Health Insurance Scheme: Improving Financial Sustainability Based on Expenditure Review. World Bank Studies. Washington, DC: World Bank. doi:10.1596/978-1-4648-1117-3. License: Creative Commons Attribution CC BY 3.0 IGO. 105  Schieber, G., Cashin, C., Saleh, K. and R. Lavado. 2012. Health Financing in Ghana. Washington, DC: World Bank. doi:10.1596/978-0-8213-9566-0. License: Creative Commons Attribution CC BY 3.0. 106  Wang, Huihui, Nathaniel Otoo, and Lydia Dsane-Selby. 2017. Ghana National Health Insurance Scheme: Improving Financial Sustainability Based on Expenditure Review. World Bank Studies. Washington, DC: World Bank. doi:10.1596/978-1-4648-1117-3. License: Creative Commons Attribution CC BY 3.0 IGO. 107  MoH, 2015. Ghana Family Planning Costed Implementation Plan 2016 –2020, MoH, Accra, Ghana. 108  MoH, 2015. Ghana Family Planning Costed Implementation Plan 2016 –2020, MoH, Accra, Ghana. 109  MoH and Oxford Policy Management, 2018. A roadmap for sustainability and transition from external finance: mapping donor and domestic financing for the health sector in Ghana and planning for the future. 110  WHO Global Health Expenditures Database in MoH and Oxford Policy Management, 2018. A roadmap for sustainability and transition from external finance: mapping donor and domestic financing for the health sector in Ghana and planning for the future. 111  Global AIDS Monitoring Report, 2019. http://aidsinfo.unaids.org/ 112  WHO Global TB Database, 2017. https://www.who.int/tb/data/en/ 113  MoH and Oxford Policy Management, 2018. A roadmap for sustainability and transition from external finance: mapping donor and domestic financing for the health sector in Ghana and planning for the future. 114  Ibid. 115  MoH and Oxford Policy Management, 2018. A roadmap for sustainability and transition from external finance: mapping donor and domestic financing for the health sector in Ghana and planning for the future. http://aidsinfo.unaids.org/ https://www.who.int/tb/data/en/ Pharos Global Health Advisors | 41 • Chapter 4: Ghana Country Case Study from the FP program in 2016, Ghana is already facing a scenario of reduced donor funding (Figure 4.3).115 Addi- tionally, although Ghana does not currently meet USAID thresholds for FP program transition and donor infor- mants suggest that USAID is not actively preparing for FP transition in-country, US funding for important FP service partners in Ghana, such as MSI and PPAG has sharply declined because, these organizations have abstained from signing the Mexico City Policy. FIGURE 4.2: Projected donor contributions for six priority health programs in Ghana: 2017-2025 (Source: OPM 2018)* 300 250 200 150 100 50 0 2017 2018 2019 2020 2021 2022 2023 2024 2025  CHPS    Family Planning  HIV/AIDS  Immunization  Malaria  Tuberculosis   Other Health Interventions 20.0 18.0 16.0 14.0 12.0 10.0 8.0 6.0 4.0 2.0 0.0 FIGURE 4.3: Figure 4.3: Estimated and projected donor contributions for FP in Ghana: 2010-2025 (Source: OPM 2018)* 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025  DFID    UNFPA  USAID Do no r C on tr ib ut io ns (M ill io ns U SD ) 1.5 2.7 1.5 1.31.3 1.3 13 15 7.4 7 7 7 7 7 7 5.5 4 2.5 1 1.61.61.61.61.62.41.20.81.8 2 0.9 5.65.1 2 0.7 1.3 2 0.6 116  Center for Global Development and Kaiser Family Foundation (2018). The USG International Family Planning Landscape: Defining Approaches to Address Uncertainties in Funding and Programming. Discussion summary. Do no r C on tr ib ut io ns (M ill io ns U SD ) *  These estimates were prepared by OPM researchers in 2018 through extensive in-country consultations with all major health donors in Ghana. In March 2020, officials at USAID headquarters informed us that these estimated declines in US assistance for FP in Ghana through 2025 are inconsistent with current plans to maintain fairly steady funding levels to the program. In this report, we continue to cite OPM’s well-researched report but acknowledge USAID’s updated information. Transitions in Family Planning | 42 • Chapter 4: Ghana Country Case Study Financing of FP and Other Health Programs Financing of Family Planning Complete and up to date information on FP financing is not available for Ghana, but what is known suggests that the program is heavily donor dependent. A recent report estimates that the government contributes around US $1 million of a total FP expenditure of around US $10 million117 – presumably for commodities alone, since total FP funding needs are estimated at 4-5 times this amount. Donor funding comes from two main donors– UNFPA and USAID–with the West African Health Orga- nization (WAHO) providing commodity financing and capacity building on a smaller, ad hoc basis.118 DFID ended its commodity support in 2016 but continued to support FP indirectly through the Health Sector Support Program (HSSP), which concluded in 2018.119 Current government strategies for FP financing include the mobilization of additional domestic budgetary resources and the incorporation of FP clinical services in the NHIS package.120 The GoG has established a dedi- cated budget line to finance essential health commod- ities, including contraceptives. However, respondents indicated that execution remains a challenge: while the GoG does “fund” FP in the budget, the money is not always disbursed in full or according to schedule. In practice, the GoG did not contribute to the direct cost of FP commodities from 2016-2018.121 Only in 2019 has US $3 million in government funding been released for the procurement of condoms, but this allocation is offi- cially directed towards the HIV program.122 Moreover, as contraceptive funding is lumped with other health programs’ commodity funds, the FP program cannot track formal government allocations and may receive varying proportions of this line item total each year. The details of how FP clinical services may be included in the NHIS are not yet known and are largely dependent on the outcome of a pilot currently taking place. Fund- ed by DFID and implemented by the NHIA and MSI, the pilot is testing the provision of clinical methods (perma- nent, long-acting, and injectable contraceptive services) under the NHIS using a case-based billing code. Prelimi- nary actuarial analysis is promising, as is the increase in utilization of LARCs under the pilot (Figure 4.4). FIGURE 4.4: Total and percent change in new FP uptake by method following the initiation of the Nhis pilot (Source: Marie Stopes International, 2018) 2000 1500 1000 500 0 Cumulative new FP uptake  Feb-Apr 2018 |   May-July 2018 New acceptors of Norigynon New Acceptors of Depo Provera New Acceptors of Implanon New acceptors of Copper-T (IUD) New acceptors of Jadelle 40% 30% 20% 10% 0 -10% -20% -30% Percentage change in new FP uptake New acceptors of Norigynon New Acceptors of Depo Provera New Acceptors of Implanon New acceptors of Copper-T (IUD) New acceptors of Jadelle FP method results from 3 months after 1st May for 7 pilot districts 117  MoH and Oxford Policy Management, 2018. A roadmap for sustainability and transition from external finance: mapping donor and domestic financing for the health sector in Ghana and planning for the future. 118  Government respondents. 119  MoH and Oxford Policy Management, 2018. A roadmap for sustainability and transition from external finance: mapping donor and domestic financing for the health sector in Ghana and planning for the future. 120  Ghana: FP2020 Core Indicator Summary Sheet: 2017-2018 Annual Progress Report. 121  In-country respondent. 122  Ibid. N ew U se rs N ew U se rs Pharos Global Health Advisors | 43 • Chapter 4: Ghana Country Case Study The national FP Costed Implementation Plan (CIP) esti- mates that total annual FP program resource needs from 2016 to 2020 are between US $40-50 million.123 In the CIP, commodities and service delivery were estimat- ed at 76% of the total cost, at 14% and 62% respectively. However, as a government respondent indicated, most current FP financing is off-budget, and the government “doesn’t even know how much money is spent, so it’s impossible to plan or predict costs.” Unlike some other FP2020 focus countries, Ghana has not conducted an FP spending assessment. It has completed a recent NIDI survey, but the GoG has not yet validated or released any FP financing survey results. Projected FP resource requirements are available in Ghana through 2025. However, these do not appear to be officially recognized by the GoG, nor are they reflected within domestic planning. Analysis by Oxford Policy Management (OPM) estimates that fully costed FP resource needs would total US $46 million in 2018, rising to US $70 million in 2025 (Figure 4.5).124 This amount includes all program costs categorized into seven areas: demand creation; service delivery; contra- ceptives; contraceptive security; policy and enabling environment; financing; and stewardship, management, and accountability. GoG on-budget financing and devel- opment partner (DP) funding are primarily directed towards commodity procurement and delivery, and their current funding levels are considered “significantly lower than the fully costed needs.”125 Fiscal Challenges of Simultaneous Health Transitions Declines in donor funding for HIV, TB, malaria, and immunization are taking place concurrently in Ghana. This process is not well choreographed among donors, or between donors and government. As stated in the OPM report, development partners “do not all have simi- lar or aligned transition plans, if they have plans at all.”126 However, indicators of impending transition include a reduction in the number of donors funding health, shrinking donor allocations, and stronger conditions around domestic co-financing. 123  Government of Ghana. 2015. Accra: Ghana Health Service. 2015. Washington, DC: Futures Group, Health Policy Project. Ghana Family Planning Costed Implementation Plan. 124  MoH and Oxford Policy Management, 2018. A roadmap for sustainability and transition from external finance: mapping donor and domestic financing for the health sector in Ghana and planning for the future. 125  Ibid. 126  Ibid. FIGURE 4.5: FP Financing Gap Projections (million USD) (Source: OPM, 2018)   Development Partner Off-budget Family Planning Funding    Family Planning On-budget Expenditure  Family Planning Needs  FP Commodity Needs Only 80 70 60 50 40 30 20 10 0 Fully Costed FP Financing Gap FP Commodities only could be affordable 2018 2019 2020 2021 2022 2023 2024 2025 M ill io ns U SD Transitions in Family Planning | 44 • Chapter 4: Ghana Country Case Study Some long-standing donors have recently left the Ghanaian health sector, including the European Union and the Danish International Development Agency, with more donors anticipated to transition out of health and of aid to Ghana in general.127 For example, DFID, which has provided over 10% of external health financing in Ghana since 2010, intends to depart from direct health sector assistance in 2019 and from all health-related TA activities by 2022.128 According to OPM, USAID antici- pates a reduction in all health activities in Ghana starting in 2021, and Gavi expects Ghana to become fully self-fi- nancing in immunization by 2027 (Table 4.1).129 Co-financing payments are an opportunity to ensure domestic financial sustainability, but current program estimates suggest a very large increase in required domestic funding in the next few years. Gavi, the Glob- al Fund, and PEPFAR have incorporated significant co-financing requirements into their grant packages to prepare the country for national “ownership” of health programs and to promote sustainable financing. In 2019 alone, Ghana’s expected co-financing require- ments include US $3.5 million to Gavi, US $227.2 million to the Global Fund, and US $8.3 million to PEPFAR.131 Moreover, for the period 2019-2025, Ghana’s co-fi- nancing requirements will total over US $2 billion.132 Whereas informants described loose monitoring and enforcement of co-financing requirements in the past, 127 Ibid. 128 Ibid. 129 Ibid. 130 See Annex 5 for full OPM data. 131  Ibid. 132 Ibid. TABLE 4.1: Timeline of donor health aid withdrawal in Ghana through 2027 (Source: OPM, 2018)130 Donor FP HIV/AIDS Immunization Malaria TB Health TA DFID Ended 2017; some TA ongoing to 2022 Ends 2019 Ends 2022 Gavi Accelerated transition begins 2021; full transition by 2027 Global Fund Medium/long-term Medium/long-term Medium/long-term JICA Ended 2016 Medium/long-term KOFIH Medium/long-term UNFPA Medium/ long-term Low-level aid ongoing USAID Expected to decline starting 2021* Expected to decline starting 2021 Expected to decline starting 2021 Medium/long-term World Bank Ended 2015 Ended 2014 Medium/long-term WHO Medium/long-term Medium/ long-term Medium/long-term Medium/long-term Medium/long-term * See page 41 for updated information from USAID headquarters regarding future US financing of the Ghana FP program. Pharos Global Health Advisors | 45 • Chapter 4: Ghana Country Case Study particularly for the Global Fund, current consequences of defaulting on co-financing agreements have become more severe, resulting in losses of and delays in grant funding. According to an informant, the Global Fund is now paying greater attention to Ghana’s co-financing commitments as spelled out in official letters and has reduced recent grant awards due to noncompliance. Total co-financing projections for HIV/AIDS, TB, malar- ia, and immunization through 2025 are presented in Figure 4.6. The GoG is estimated to require a US $206 million increase in annual domestic financing from 2017 to 2025, which will also coincide with a US $124 million decline in external financing.133 In comparison, total domestic government expenditure on health in 2016 was approximately US $523 million.134 Thus, the GoG must allocate approximately US $729 million, or 1.4 times its 2016 domestic health budget, simply to maintain 2016 health expenditure levels while meeting co-financing arrangements in 2025. To cover lost donor funds, the 2025 GoG must further increase its health expenditures to US $853 million, or 1.6 times its 2016 domestic health budget. Ghana’s ability to mobilize expanded resources for co-financing is not ensured. Domestic funding of the immunization program has already run into payment difficulties.135 At present, only 10% of government health funds are earmarked for the MoH to satisfy co-financ- ing requirements,136 which does not meet the 15-20% GHE requirement illustrated in Figure 4.6. As a result, many major disease areas are lobbying for a special earmarked tax or levy to fund their program.137 However, additional health taxes are viewed as “not fair for Ghana- ians” (Government respondent), with the implication that priority health programs need to be more account- able for current funding before seeking more resources through new levies. 133  MoH and Oxford Policy Management, 2018. A roadmap for sustainability and transition from external finance: mapping donor and domestic financing for the health sector in Ghana and planning for the future. See Annex 5 for full data. 134  Ghana MoH, 2018. Medium term expenditure framework for 2018-2021. https://www.mofep.gov.gh/sites/default/files/pbb-estimates/2018/ 2018-PBB-MoH.pdf 135  Ibid. Based on OPM interviews with Gavi and MOH, co-financing requirements have been in arrears since 2016. 136  Government respondents. 137 Government respondent. FIGURE 4.6: Ghana’s projected co-financing requirements: 2017-2025 (Source: OPM, 2018)  Tuberculosis    Malaria  Immunization  HIV/AIDS  Cofinancing as % GHE 400 350 300 250 200 150 100 50 0 2017 2018 2019 2020 2021 2022 2023 2024 2025 25% 20% 15% 10% 5% 0 M ill io ns U SD Pe rc en t o f G ov er nm en t H ea lth E xp en di tu re https://www.mofep.gov.gh/sites/default/files/pbb-estimates/2018/2018-PBB-MoH.pdf https://www.mofep.gov.gh/sites/default/files/pbb-estimates/2018/2018-PBB-MoH.pdf Transitions in Family Planning | 46 • Chapter 4: Ghana Country Case Study UHC, FP, and Other Priority Health Programs Priority health program transition is situated within broader discussions on UHC. UHC is not a new concept for Ghana. Starting with the Alma Ata “Health for All Movement,” the country adopted the Ghana Primary Health Care Strategy in the late 1970s and early 1980s; strengthened District Health Systems in the 1990s; introduced and scaled up the CHPS starting in 2000; and established the NHIS in 2003. However, “despite the near universal acceptance of the UHC concept among the majority of stakeholders in the health sector, there remains no consensus over what Ghana needs to do to achieve UHC, nor the clear goal and targets.”138 The UHC Roadmap, currently in draft form, is intended to provide needed consensus and chart a course toward achieving UHC by 2030. The NHIS is the GoG’s primary strategy for moving to UHC and reaching infectious desease program sustain- ability,139 but this plan will be challenging to implement. The UHC Roadmap outlines plans to consolidate the gains made with reproductive, maternal, neonatal, child and adolescent health (RMNCAH) and communica- ble diseases and integrate them into the overall health system, funded by the NHIS. As the Roadmap indi- cates, vertical disease programs were the hallmark of the Millennium Development Goals (MDGs); they now require integration as part of “SDG thinking” to ensure their sustainability. However, the NHIS has significant challenges; it is in deficit as claims have outpaced reve- nue, and delayed contributions from the NHIS levy exac- erbate this issue. This uncertain funding scenario has impacted the efficiency of both NHIA internal operations and health provider activities, since both lack incentives to be cost-effective. NHIS coverage remains low, esti- mated at 40% of the total population in 2014 with large variations regionally in coverage as well as amongst the informal sector and the poor.140 While GoG policy assumes that infectious disease programs will transition to NHIS and be integrated with other health services, the prospects for full integration are questionable. Currently, NHIS policies and donor funding practices reinforce vertical service delivery.141 For example, the Global Fund pays NHIS premiums for HIV-positive individuals to access opportunistic infection treatment in NHIS-accredited facilities, but these same patients must seek anti-retroviral therapy (ART) from HIV clinics because ART drugs are excluded from the NHIS benefit package.142 Ghanaian policymakers have expressed doubts about the HIV program’s proposed inclusion of ART services within the NHIS: previously, the HIV program enjoyed large amounts of donor fund- ing, but now they “claim they’re broke and want to be included in NHIS…if we’re not careful, these huge disease areas with high expenditures will eat us up.” In contrast, another government respondent acknowledged that while the NHIS cares about costs, “they [the NHIA] must listen to government verdict: if government [e.g., the MoH or Ministry of Finance] says it’s included, then it is.” None of the respondents mentioned formal processes for priority-setting within the NHIS benefits package, although an actuarial study was ongoing at the time of writing. In addition, Ghana has started to engage with health technology assessments as a means of moving towards more evidence informed policy decisions.143 Within this milieu, FP may have a better chance of being included under NHIS for several reasons: it is not viewed as a vertical program as it is integrated in the GHS; it does not entail large expenditures such as those for HIV; and its future inclusion in the NHIS is implicit based upon the clinical FP pilot implemented with the support of MSI and DFID. 138 MoH, 2019. Overview of the UHC Roadmap for Ghana For Discussion at the Health Summit 2019. MoH, Accra, Ghana. 139 Ibid. 140  Wang, H. Otoo, N. and L. Dsane-Selby. 2017. Ghana National Health Insurance Scheme: Improving Financial Sustainability Based on Expenditure Review. World Bank Studies. Washington, DC: World Bank. doi:10.1596/978-1-4648-1117-3. License: Creative Commons Attribution CC BY 3.0 IGO. 141  UHC2030 International Health Partnership, 2019. Perspective from Health Programs on Sustainability and Transition from External Funding. Report of a meeting held at Chateau de Penthes Geneva, Switzerland, May 2019. 142  The NHIA reported that the NHIS currently pays for opportunistic infection treatment and lab tests performed using HIV kits (which are donated, so this practice is considered “double-dipping”). The NHIS does not support ART. 143  See: https://www.idsihealth.org/blog/ghanas-minister-of-health-launches-the-national-hta-steering-committee-and-calls-for-hta- institutionalisation-in-the-country/ https://www.idsihealth.org/blog/ghanas-minister-of-health-launches-the-national-hta-steering-committ https://www.idsihealth.org/blog/ghanas-minister-of-health-launches-the-national-hta-steering-committ Pharos Global Health Advisors | 47 • Chapter 4: Ghana Country Case Study Procurement and Supply Chain Organization of Health Delivery Systems Ghanaian health structures have been organized to improve decentralized management and service deliv- ery. Institutionally, the health sector is stewarded by the MoH, which is responsible for policymaking and moni- toring and evaluation (M&E) of progress in achieving sector targets. The Ghana Health Service (GHS), estab- lished in 2001, is responsible for planning and manage- ment of health services and provides decentralized authority to Regional and District Health Services. As part of the GHS, the Community-Based Health Plan- ning and Services (CHPS) was started as a pilot in 1994 to improve PHC access. To date, it is estimated that there are 3,175 functional CHPS zones and 1,410 functional CHPS compounds, employing around 15,900 Commu- nity Health Nurses.144 The CHPS delivers a compre- hensive package of PHC services but is overburdened. PHC services include maternal and reproductive health, neonatal and child health services (including immu- nization), minor ailments, and health education. There have been changing definitions of the basic package of CHPS interventions, particularly in relation to infectious disease programs, which has added to the burden of frontline workers. Not all CHPS zones are considered functional; only 74% have an operating site, only a half have either a functioning vaccine fridge or a cold box, and only 41% have trained Community Health Officers to provide services.145 Issues with CHPS functionality as well as an expanding service package may reduce these facilities’ capacity to provide quality FP services, and these challenges may be further exacerbated through transition because of the program’s heavily reliance on donor funding. For example, decline in external funds for health may negatively impact the contraceptive meth- od mix, particularly the provision of LARCs, given the GoG’s reliance on donors for commodities, training and, in some cases, service delivery (e.g. through NGO-sup- ported outreach). The GHS mandate and structure do not adequately engage the private sector. Only the Christian Health Association of Ghana (CHAG), a network of 302 faith- based health facilities, has been integrated within the GHS, while other for-profit and not-for-profit providers, including MSI and PPAG, operate at the periphery of the health system.146 Therefore, with the exception of CHAG, the private sector is largely excluded from access to subsidized commodities, accreditation, and the GHS supervision structure.147 This situation exists despite significant private sector involvement in PHC activi- ties, including the provision of one-third of FP services in Ghana.148 The private sector also plays a role in the supply of FP commodities. For example, GSMF Interna- tional is the largest private sector supplier of contracep- tives in Ghana and has a distribution network of more than 4,000 outlets across the country.149 Most FP services provided in the private sector are short-term methods. This situation may reflect a lack of access to LARC commodities among private providers, except for those supported through social franchising and social marketing programs. Pharmacies and chem- ical sellers also provide over-the-counter FP methods, such as pills, condoms, and emergency contraception, primarily in urban areas. 144  Rowan, A., Gesuale, S., Husband, R. and K. Longfield, 2019. Integrating Family Planning into Primary Health Care in Ghana: A Case Study. Washington, DC: Results for Development. 145  Rowan, A., Gesuale, S., Husband, R. and K. Longfield, 2019. Integrating Family Planning into Primary Health Care in Ghana: A Case Study. Washington, DC: Results for Development. 146 Ibid. 147  Rowan, A., Gesuale, S., Husband, R. and K. Longfield, 2019. Integrating Family Planning into Primary Health Care in Ghana: A Case Study. Washington, DC: Results for Development. 148 Ibid. 149 MoH, 2015. Ghana Family Planning Costed Implementation Plan 2016 –2020, MoH, Accra, Ghana. 150 Government respondents. Transitions in Family Planning | 48 • Chapter 4: Ghana Country Case Study Procurement and Supply Chain for FP and Other Major Health Programs The GHS is responsible for the procurement and distri- bution of essential medicines and medical supplies (EMMS), including FP commodities. The EMMS supply chain receives external support through the USAID Glob- al Health Procurement and Supply Chain Management (PSM) project.150 Chemonics, the implementing partner for the PSM project, acts as the procurement agent for all USAID-funded commodities, including for FP. The proj- ect also provides TA for the national supply chain system, covering warehousing, distribution, information, logistics, and capacity building. The FP supply chain currently uses a private sector warehousing system funded by the PSM project.151 When transition occurs, the GoG may choose not to contract private sector warehouses or may find that the cost of private contracting is not affordable, creating serious risks to the FP supply chain. Forecasting and quantification of FP commodities is done at national level under the leadership of the GHS. There is an Interagency Coordinating Commit- tee for Contraceptive Security (ICC-CS) chaired by the National Population Council. The ICC-CS meets quar- terly to review stock status and coordinate forecasting, procurement, and supply across partners. The ICC-CS has a supply plan showing what items are coming into the country, when they arrive, and who is funding them. From 2016-2018, external donors funded all contracep- tive commodities in Ghana.152 (In this period, the GoG contributed in-kind resources for commodity-related expenditures such as warehousing and personnel costs. Starting in 2019, the GoG is reportedly begun contribut- ing to the direct cost of commodities.153) Donor funding of FP commodities helps to ensure consumer choice of contraceptive method in the public sector.154 However, choice in the private sector is considered limited, partic- ularly for LARCs. Additionally, private providers (except for CHAG) use a separate FP commodity procurement system, which contributes to difficulties in making accu- rate contraceptive forecasts for the entire country.155 FP commodity financing fluctuates from year to year but reportedly does not result in significant stock-outs because consumption projections are not realized. In-country respondents reported that, in 2016, 74.6% of the forecast commodity resource requirements were supplied by donors, leaving a 25.4% annual commodity funding gap. In 2017, only 55.9% of projected resource requirements were filled by donors, due to UNFPA fund- ing shortfalls and DFID’s departure. In 2018, this figure increased to 75.2% (Figure 4.7). On average over this period, 31.5% of projected annual commodity resources went unfunded, representing between US $2 million and US $3.6 million per year. Despite these large shortfalls in financing, the country does not run out of commodities. This result may be due to two factors: overestimated demand and unmet need. Government and partner respondents favored the former explanation; as noted by a respondent, “By mid-year, when the forecast is reviewed, the assump- tions used for consumption are not realized.” Interview- ees did not suggest that the lack of stock-outs (despite 151 Partner respondent. 152 In-country respondent. 153 In-country respondent. 154 MoH, 2015. Ghana Family Planning Costed Implementation Plan 2016 –2020, MoH, Accra, Ghana. 155 Ibid.  Donor Contributions    Commodity Funding Gap 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 2016 2017 2018 25.4% 44.1% 24.8% 74.6% 55.9% 75.2% FIGURE 4.7: FP Commodity Financing Gap: 2016-18 (Source: Country Informant) Pharos Global Health Advisors | 49 • Chapter 4: Ghana Country Case Study commodity funding gaps) was the result of unmet demand. However, given Ghana’s 33.6% rate of unmet contraceptive need, this could be a significant contrib- uting factor to the annual discrepancy between forecast and realized consumption. The fact that stock-outs at the central and regional levels are avoided despite large annual commodity funding gaps may also explain why the GoG is hesitant to contribute domestic resources for commodities. Where stock-outs do exist at health facilities, they are considered “artificial” due to maldis- tribution (i.e., over- and under-supply at service delivery points).156 Procurement and supply chains for other priority health programs – HIV and TB – also remain vulnerable as part of transition. Currently, all program commodities are integrated within the EMMS except for HIV and TB which are managed separately.157 As highlighted by WHO’s analytical work, stock-outs of HIV and TB drugs have occurred not because of a lack of funding, but because these medicines are transported along sepa- rate but near-identical vertical supply chains, resulting in unnecessary, delay-inducing duplication of delivery efforts.158 There are plans in place as part of Global Fund transition to look at integration of HIV and TB within the EMMS.159 However, according to one respondent, the timing of the Global Fund transition assessment coin- cided with government elections and political change. As reported, this work towards HIV/TB integration was viewed as part of the previous administration and was not embraced. There are practical systems challenges with the inclusion of commodities and distribution costs within the NHIS. Health facilities use part of their NHIS reimbursement to pay for EMMS from the GHS regional stores. Howev- er, bottlenecks occur in practice because payment of EMMS costs depends on reimbursement from the NHIS, which is often significantly delayed. There are also challenges with the inclusion of donor-funded commod- ities in the NHIS. Commodity costs should not be reim- bursed by the insurance system if they are already paid for by donors, but some health facilities have sought full reimbursement for donor-provided malaria commodi- ties as well as contraceptives included in the FP pilot.160 In addition, the NHIS has no intention of being involved in commodity procurement; as stated in an interview with NHIS officials, “Someone has to buy it, then we will reimburse.” Technical Capacity As an FP2020 pledging country, Ghana has committed to improved FP program data collection and utilization. At the national level, this M&E initiative is primarily support- ed by the Track20 project,161 which works with FP2020 countries to train dedicated FP M&E officers. Track20 and other partners support the GHS’s efforts to improve FP data quality and its utilization in decision-making and priority-setting. TA in this area has mainly focused on program performance and not financing, as FP2020 has yet to report verified expenditure data for Ghana. Internally generated FP program data are utilized in the ICC-CS and other technical working groups in order to build consensus on commodity forecasting, FP2020 progress, and technical interventions.162 Data analy- sis estimates unmet need and monitors FP outcomes for specific vulnerable sub-groups such as adoles- cents. However, not all government respondents were convinced of FP data accuracy; some suggested that Ghana’s relatively weak FP program indicators were the result of underreporting. FP logistics data are also improving but require ongo- ing TA. The flow of contraceptive information and data from service delivery points through the system is weak. At the national level, stock monitoring and reporting are routine, but stock information coming from devolved 156 MoH, 2015. Ghana Family Planning Costed Implementation Plan 2016–2020, MoH, Accra, Ghana. 157 Government respondent. 158  UHC2030 International Health Partnership, 2019. Perspective from Health Programs on Sustainability and Transition from External Funding. Report of a meeting held at Chateau de Penthes Geneva, Switzerland, May 2019. 159 Government respondent. 160 Government respondent. 161 http://www.track20.org. 162 Government respondents. http://www.track20.org Transitions in Family Planning | 50 • Chapter 4: Ghana Country Case Study levels of the health system is incomplete, unreliable, and delayed.163 The FP-CIP notes that routine reporting of stock levels and performance monitoring of the supply chain remain inadequate, with gaps in accountability and responsibility across agencies. Additionally, with multiple stakeholders involved in supply chain activi- ties, coordination and sharing of data on contraceptive supply remain insufficient.164 The required TA to address these issues currently comes from donors and thus represents another area of risk in transition. Enabling Factors: Political Commitment to FP and Legal & Human Rights Risks It is an FP2020 priority to increase political commitment for FP, but the results in Ghana to date are mixed. Ensur- ing that financing and service availability do not preclude access to FP services constitutes an important compo- nent of political commitment. To achieve this goal, as mentioned above, the government has approved a dedi- cated budget line to finance essential health commod- ities, including contraceptives, and is currently in the process of piloting access to clinical FP services in the NHIS benefit package. This strategy complements national efforts to ensure that health financing reforms in the country are oriented towards attainment of UHC. Ghana has also been included in the Global Financing Facility (GFF) for women, children and adolescents, following the replenishment event in 2018. The GFF will provide an opportunity for additional investment in FP which could be oriented towards sustainability and tran- sition, but the GFF will entail mainly external funding and may not translate into larger domestic commitments. Ghana does not have high-level political champions of FP. The most senior political officials in Ghana are gener- ally not aware of any specifics regarding the national FP program, including its major challenges and weakness- es. Individuals tasked with development planning tend to focus on other sectors such as infrastructure rather than the health sector, and the contribution of FP to achieving social and economic goals is not recognized or discussed publicly. A few FP advocates—primarily women—hold positions of prestige in government and civil society, and they are actively seeking to elevate the issue of FP to a national priority. However, they have not been able to recruit other senior politicians, especially senior male offi- cials, to become champions of this cause. This situation exists despite recognition of rapid population growth as a development issue within the Long-term National Devel- opment Plan of Ghana (2018-2057). Unmet need is high in Ghana, suggesting that repro- ductive rights are not realized for all women and girls. Only 47% of married women’s FP needs are currently being met, of which 39% is satisfied by modern meth- ods.165 Unmet need is about the same in urban and rural areas at 26% and 28% respectively.166 However, there are distinct regional patterns to FP use, with mCPR ranging from 32% in Volta region to 11% in Northern region.167 Adolescent girls aged 15-19 have the highest unmet need for FP at 51%.168 This level of unmet demand frequently results in unwanted pregnancy or recourse to abortion, including unsafe abortion. It is estimated that 163 MoH, 2015. Ghana Family Planning Costed Implementation Plan 2016 –2020, MoH, Accra, Ghana. 164 Ibid. 165 Ghana Statistical Service (GSS), Ghana Health Service (GHS), and ICF International. 2015. Ghana Demographic and Health Survey 2014. 166 Ibid. 167 Ibid. 168 Ibid. A young mother and her child receive care at a community health clinic in Ghana. Photo: USAID/Ghana, 2018. Pharos Global Health Advisors | 51 • Chapter 4: Ghana Country Case Study 22% of girls under 18 and 39% of women under 20 have had a pregnancy,169 which is high compared to other sub-Saharan African nations. Informants indicated that Ghana’s laws and regulations surrounding adolescent contraceptive use are sufficiently enabling, and the high rates of teenage pregnancy result more from cultural norms, social practices, and provider biases. In particu- lar, respondents pointed to the widespread belief among Ghana’s adolescent girls (as well as their families and male peers) that teenage motherhood is an essential component of womanhood. The individual and societal challenges of adolescent pregnancy are recognized by some advocates within and outside government, but this issue has not been central to the wider development agenda, political discussions, or financing decisions. Client OOP expenditure is ubiquitous in Ghana and contributes to FP inequities. OOP expenditure in Ghana is higher than or about the same as in other countries with similar per capita incomes, and it is twice the thresh- old recommended by the WHO.170 OOP expenditure affects access to a range of health services, including FP. While FP is supposed to be free in the public sector, it is estimated that nearly all public sector clients do make some form of payment for FP.171 Thus FP service charges “deviate from the official government subsi- dized FP service rates.”172 If the NHIS FP pilot is scaled, NHIS-accredited private providers would also offer free clinical FP methods. This change would require provider and consumer education so that co-payments are not introduced or paid for clinical FP services. A Ghanaian study showed that women’s type of earn- ings has a bearing on use of modern contraceptives with women who earn a cash income more likely to use modern contraceptives as compared to women who are not paid or paid in-kind.173 These results suggest that women’s financial dependence and lack of income may limit use of modern contraceptives. However, these financial barriers do not seem to be recognized or prior- itized by Ghanaian officials amidst the many other barri- ers to contraceptive use, such as consumer knowledge, women’s concerns about side effects, physical access to services, religious and cultural norms, and provider bias. 169 Ibid. 170  Schieber, G., Cashin, C., Saleh, K. and R. Lavado. 2012. Health Financing in Ghana. Washington, DC: World Bank. doi:10.1596/978-0-8213-9566-0. License: Creative Commons Attribution CC BY 3.0. 171  Stover, J. and R. Chandler, 2017. Expenditures on Family Planning in FP2020 Focus Countries in 2015. Track20 Project for the International Family Planning Expenditure Tracking Advisory Group. 172 https://ghana.unfpa.org/en/news/taking-stock-financing-family-planning-services-reach-ghanas-2020-goals. 173  Aviisah, P.A., Dery, S., Atsu, B.K., Yawson, A., Alotaibi, R.M., Rezk, H.R., and C. Guure, 2018. BMC Women’s Health. 18:141 https://doi.org/10.1186/s12905- 018-0634-9. https://ghana.unfpa.org/en/news/taking-stock-financing-family-planning-services-reach-ghanas-2020-goals Transitions in Family Planning | 52 • Chapter 4: Ghana Country Case Study Summary of Risks and Key Options for Consideration Key options for consideration to improve Ghana’s readiness for FP transition are summarized in Table 4.2 below and explained in detail in the remainder of this section. TABLE 4.2: Key options for consideration to improve Ghana’s readiness for FP transition Transition Risk Area Key Options for Consideration Financing of FP and Other Health Programs • Incorporate learnings and include FP clinical services in the NHIS benefits package as validated through actuarial analysis and the pilot program • Develop realistic cost estimates for the FP program and use these to guide planning and budgeting • Introduce a centralized FP budget line at the national level with ring-fenced funding • Introduce FP co-financing arrangements and clear timescales for transition of donor financing for FP to domestic financing • Conduct and publish annual FP expenditure analysis including OOP expenditure • Develop the Ghana GFF investment case so that it is prioritized, affordable, and realistic and so it address- es sustainability and transition of FP and other RMNCAH services • Align externally supported programs with domestic policies and incentives as part of UHC, so that silos are eliminated, inefficiency is reduced, and national ownership is enhanced Procurement and Supply Chain • Develop more precise forecasts so that FP requirements are accurate and drive domestic commitments, and pinpoint the cause of continued discrepancies in projected versus realized consumption • Develop timeframes and milestones for transitioning support for procurement and supply chain manage- ment • Build domestic capacity for private supply chain contracting or integrate the current supply chain into the national system, building off what already exists • Include the private sector within commodity forecasts in order to improve their accuracy, and encourage the private sector to increase participation in commodity procurement and supply • Monitor FP supply at service delivery points to rectify “artificial” stockouts and improve reporting Technical Capacity • Develop a comprehensive and practical health transition strategy that is led by the GoG and includes all major health donors/programs, including FP • Introduce more systematic use of HTA governance, processes, and analytics to inform design of benefits packages and build FP technologies and services into the HTA program and UHC benefits package • Transfer FP data analysis and survey skills to national institutions Enabling Factors • Improve FP service access in under-served regions and for the poor and adolescents through public-pri- vate-partnership (e.g. contracting out to NGOs) • Publicize the availability of free FP services through the NHIS and enforce rules prohibiting the collection of user fees at NHIS-affiliated facilities • Using the demographic dividend as an organizing framework, elevate the societal and economic benefits of FP to make rights more central to the discourse of FP programming as inputs to advocacy and policy dialogue at all levels of government Pharos Global Health Advisors | 53 • Chapter 4: Ghana Country Case Study Financing Risks and Options for Consideration Ghana needs more money for health, which is assumed to come from the NHIS. Ghanaian respondents indicat- ed that sustainable financing of FP—and other major health programs—would likely come through the NHIS. However, the NHIS is not currently prepared to support these programs. There is a need to address ongoing challenges with NHIS’s financial solvency and stability while developing a sustainable, evidence-based bene- fits package. There is also need for greater efficiency in both the NHIA and the GHS and adoption of priority setting mechanisms, given fiscal constraints. Respondents also expressed the desire for great- er accountability of the high-cost infectious disease control programs (including HIV, TB, and malaria) before consideration of their inclusion within the NHIS, as these programs have been perceived as bloated or over-funded. (This is likely not the case at present, but the perception may have been more accurate when there were many well-funded bilateral and multi-lat- eral donors contributing to these disease programs.) Ongoing political debates about donor-backed health programs’ accountability could delay the incorporation of FP within the NHIS. Moreover, although FP will not impose the same large financial burden on NHIS as other programs such as malaria, FP does not have the same lobbying power as the other disease programs. More needs to be done by the FP community in Ghana to elevate the importance of FP service inclusion in the NHIS. The argument for inclusion could be reinforced by evidence from other countries supporting the incorpo- ration of FP within national health insurance schemes (Box 4.2). Ghana also needs more health impact for money, but specific strategies to improve efficiency in the health sector have yet to be identified. There are inconsis- tencies between the central management of vertical programs and the devolved service delivery system under the GHS. Within the NHIS, there are reportedly ineffective gatekeeper and referral systems as well as misaligned provider payment incentives that limit the role of the NHIA as a strategic purchaser.174 However, government and partner respondents did not identify specific actions or plans to improve efficiency in health spending despite the clear need for such initiatives across all health programs, including FP. The biggest financing risk for FP is that declining donor funding will not be replaced by domestic funding. While this risk applies to all priority health programs, it is of parti

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