International Development Strategy: call for evidence

Submission: MSI Reproductive Choices

About MSI Reproductive Choices

MSI Reproductive Choices (MSI) is one of the world’s largest providers of sexual and reproductive health services, and an advocate for gender equality and reproductive choice. We work in 37 countries as a key partner to ministries of health, private providers, and civil society organisations. By the end of 2021 over 34 million women globally were using a form of contraception supplied by MSI. 

Our evidence submission

1. How well is UK Official Development Assistance (ODA) targeted towards tackling extreme poverty and how effectively do the FCDO policies and programmes contribute to the achievement of Target 1.1 of SDG 1?

1.1 MSI welcomes the inclusion of girls’ education in the FCDO’s strategic priorities. Sexual and Reproductive Health and Rights (SRHR) is a key enabler for delivering on this priority, as well as on Target 1.1 of Sustainable Development Goal (SDG) 1; these issues are interconnected. Without a dedicated focus on improving SRHR, it is not possible to tackle poverty, including extreme poverty, in a credible way.

1.2 In lower income countries, under two thirds of girls complete their primary education and only one in three complete lower secondary school.

1.3 130 million girls between the ages of six and 17 are currently out of school. A girl in South Sudan is more likely to die in childbirth than finish secondary school. Pregnancy and marriage are the main reasons why adolescent girls drop out of school.

1.4 50% of these pregnancies are unplanned, with driving factors being lack of accurate information (or the prevalence of misinformation) about sexual and reproductive health, a lack of access to contraception and abortion, and sexual exploitation and abuse.

1.5 To take just one example, it is essential that the FCDO continues to invest in the WISH (Women’s Integrated Sexual Health) programme which delivers reproductive healthcare services in 27 countries in West and Central Africa and Asia. As of October 2021, we estimate that WISH has prevented 9.2 million unintended pregnancies, 3.2 million unsafe abortions, and 15,278 maternal deaths.[1] We similarly successful programmes in Uganda, Tanzania, Malawi, and Pakistan.

1.6 MSI recommends sustained investment in the WISH programme and in the United Nations Population Fund (UNFPA) if Target 1.1 is to be achieved.

2. How might the FCDO’s strategy, policies and programmes need to change as the number of people in extreme poverty grows due to the global pandemic or the effects of climate change?

2.1 MSI welcomes the publication of the Ending Preventable Deaths approach paper and the Health Systems Strengthening position paper.[2]

2.2 A comprehensive global health strategy, with a dedicated focus on SRHR would provide a framework through which to align all initiatives and improve the impact of the government’s work to achieve Target 1.1.

2.3 The Covid-19 pandemic and the speed and scale of climate change both show the need for flexibility and sustainability in the delivery of sexual and reproductive health services. Delivering services closer to home, through improved access to medical abortion, telemedicine, and contraception delivered at the most accessible level will be vital in ensuring these services are protected for the most marginalised communities as they are impacted by Covid-19 and climate change.

2.4 Facilitating partnerships between civil society, independent service providers and the communities we serve is essential in order to do this. MSI has experience of operating at scale, and in partnership with the private sector. Data from MSI’s mobile outreach teams illustrates that access can be delivered affordably at scale. It costs less than £20 per woman for MSI’s outreach teams to protect a girl or young woman from an unintended pregnancy for an average of three years, many of whom live in underserved communities with no alternative access. Providers should operate at scale in rural areas. 85% of people experiencing multidimensional poverty live in rural areas, often underserved by the public sector.[3] UNFPA estimates 12 million women have already lost access to contraception as a result of the pandemic. UNFPA estimates 12 million women have already lost access to contraception as a result of the pandemic.

2.5 In response to an increase in extreme poverty due to climate change, MSI highlights that climate change has a disproportionate impact on women, especially the women in the world with the least access to sexual and reproductive health services. The impact on women and girls, especially those without sexual and reproductive health services should be a key part of the government’s climate change response.[4] 

2.6 SRHR should never be viewed as of secondary importance to dealing with the consequences of natural disasters, water and sanitation rights, or other international development challenges. On the contrary, rates of maternal mortality, neonatal mortality, infant mortality, and sexual violence are often greater during times of crisis or instability.

2.7 There is evidence that natural disasters can increase the need travel by foot to access basic necessities. This work largely falls to women and girls, and analysis from the International Federation of Red Cross and Red Crescent Societies has found that this can lead to an increase in sexual harassment, rape, and gender-based violence.[5] 

2.8 Bringing access to reproductive healthcare services closer to home through telemedicine abortion in England, Scotland, Wales, Australia, and South Africa has been successful during the pandemic. Offering the option of telemedicine where clinically appropriate has improved access while making service delivery more flexible and efficient for health systems as a whole due to reduced waiting times.

2.9 In the event that the UK government decides to revoke permission in England[6] for mifepristone to be taken at home (the permission which enables providers in England to offer a telemedicine abortion service where safe and clinically appropriate), this would send a disastrous signal to countries around the world. Such a decision would encourage and legitimise governments in restricting access to medical abortion in the parts of the world where access is already the least reliable.

2.10 The UK government has an opportunity to show global leadership in making home use of mifepristone a permanent option, as the US Food and Drug Administration (FDA) did last year. This would be a positive endorsement of telemedicine for countries where abortion access is greatly restricted by barriers such as infrastructure, transport, stigma, civil unrest, and unsafe journeys, all of which would be mitigated for many women and girls by the ability to take abortion medication in the privacy of their own homes.

2.11 Moreover, telemedicine abortion has the support of the Royal College of Obstetricians and Gynaecologists (RCOG), the Royal College of Midwives (RCM), the National Institute for Clinical Excellence (NICE), the British Medical Association (BMA), Rape Crisis, Refuge, and the End Violence Against Women Coalition. The evidence in support of offering the option of telemedicine for early medical abortion where appropriate is overwhelming[7][8], and it is difficult to see what credible justification could be made on either a clinical or an ethical basis for removing this option and setting a precedent for other countries to do the same.

2.12 Although this decision sits with the Department for Health and Social Care (DHSC) not the FCDO, MSI strongly encourages this committee to consider the global implications and consequences of the UK government removing this service from its own citizens, while presenting itself to the world as a leader on gender equality and reproductive rights.

3. How effectively do the FCDO’s strategy, policies and programmes address the needs of women and girls in extreme poverty?

3.1 In 2014, the International Development (Gender Equality) Act committed to ensuring that all UK aid spending “meaningfully considers” gender equality. SRHR is essential for gender equality and for achieving Target 1.1.

3.2 MSI recommends that the government outline clearer outcome measurements which would establish that SRHR is included as a key indicator in its poverty reduction strategy where appropriate.

3.3 SRHR is profoundly interlinked with poverty reduction; the two areas cannot be separated. 218 million girls in middle-and-low-income countries have no access to modern contraception. 96,000 women undergo an unsafe abortion every day, risking their lives. In 2021, MSI delivered SRHR care to over 17 million people.

3.4 In middle-and-low-income countries, 218 million girls have no access to modern contraception, and 96,000 women undergo an unsafe abortion every day, risking their lives.

3.5 According to our 2019 data, one in four of our clients live in extreme poverty (on under $1.90 per day), and 40% of our mobile outreach clients live in extreme poverty.

3.6 In 2019, 70% of MSI’s mobile outreach clients were living in poverty, and 60% of MSI’s mobile outreach clients had no alternative access to their chosen contraception. 51% of MSI’s mobile outreach clients were ‘adopters,’ which means they were taking up contraception for the first time, or after a lapse in use. Mobile outreach is the most effective proven way to deliver these services to the marginalised and underserved communities while being very cost effective.

3.7 Targeted funding at programmes like WISH remains essential so that we can build safe referral pathways for women and girls in extreme poverty into sexual and reproductive health services, which is essential for achieving Target 1.1. SRHR is also essential for achieving SDGs 3 and 5.

4. How effectively does the FCDO review the outcomes of the projects and programmes it funds that tackle extreme poverty? What evidence is there that UK aid is being used to build pathways from extreme poverty to sustainable livelihoods?

4.1 MSI recommends that SRHR outcomes be recognised as key enablers in tackling extreme poverty, and that the government be held accountable to parliament for specifically and explicitly for its delivery on SRHR.

4.2 We accept that responsibility for international development now falls within the remit of the FCDO, and that there is no department which is dedicated to international development as a standalone brief. Should the FCDO’s development objectives ever come into conflict with its trade and foreign policy objectives, it is important that Target 1.1 is maintained as a priority, and that decisions are made by the FCDO with human rights and poverty alleviation held as central principles. MSI recommends that a principle to this effect be established, and that the FCDO be accountable to parliament for its adherence to said principle.

4.3 Covid-19 has shown us the necessity of equitable access to healthcare, which is necessary far beyond this particular pandemic. Such a system should include a commitment to preventative care, and a focus on the underlying health inequalities which lead to preventable deaths. The resilience and availability of healthcare, especially to the most marginalised, should be a key outcome against which FCDO policy is evaluated.

4.4 MSI recommends greater transparency around the detail and process for spending reductions to multilateral bodies, particularly in terms of how the impact of the cuts is being evaluated and reported. There remains a need for both bilateral and multilateral ODA spending. Both of these channels should be recognised as effective in achieving different objectives and should be maintained.

5. What effect have the cuts in UK ODA had on the FCDO’s ability to address extreme poverty? What evidence is there to suggest poverty was a key consideration in deciding where the cuts should fall?

5.1 The cuts to international development spending disproportionately impacted women and girls. Specifically, the cuts disrupted access to sexual and reproductive healthcare which is a key enabler in delivering on girls’ education and poverty alleviation. There was a strong perception among civil society groups that inadequate consideration was given to the long-term impact of these cuts on achieving SDGs, including extreme poverty alleviation.

5.2 Guttmacher calculates that “Every dollar spent on contraceptive services beyond the current level would save $3 in the cost of maternal, newborn and abortion care because use of contraceptives reduces the number of unintended pregnancies.”[9] The calculation is based on the investment going into a recommended package of care which has been evaluated as feasible in diverse settings around the world.[10] Contraception is the one of the most cost effective forms of preventative care, and is considered a “best buy” for its value as a life-saving intervention.[11]

5.3 The well-documented impact of Donald Trump’s ‘global gag rule’ was an estimated six million more unintended pregnancies, 1.8 million more unsafe abortions and 20,000 more maternal deaths. The government’s cuts to international development funding could have an even greater impact.

5.4 Girls’ education has rightly been identified as one of FCDO’s seven priority areas and is a key enabler for achieving Target 1.1. The overall budget for girls’ education is estimated to have been cut by at least 40% in 2021-22 compared to 2019. This estimation was put to the Secretary of State by Baroness Elizabeth Sugg during the House of Lords Select Committee on International Development and Defence oral evidence session on 27.04.2021 and was not refuted at the time.[12]

5.5 Sexual and reproductive health services and information are key enablers for delivering on girls’ education and on poverty alleviation. Investment in United Nations Population Fund (UNFPA) and WISH remains critical for delivering on these enablers for achieving Target 1.1.

5.6 The process by which the cuts policy was implemented reflects a missed opportunity to target development funding and improve effectiveness. By making the reductions while the countries impacted were in the middle of a budget cycle, without adequate civil society consultation, the government missed an opportunity to ensure that extreme poverty alleviation was meaningfully prioritised within these policy decisions.

6. How has the merger of the Foreign and Commonwealth Office and the Department for International Development affected the UK’s approach to extreme poverty?

6.1 While MSI accepts the FCDO’s assumption of responsibility for Official Development Assistance (ODA) funding, there is a risk that this could lead to a reduced focus on the enablers necessary for achieving Target 1.1.

6.2 The International Development Committee identified this risk in its report ‘Effectiveness of UK aid: potential impact of FCO/DFID merger’[13] which found that merging the two departments could lead to a weaker prioritisation of poverty.