International Development Committee Inquiry: Sexual and reproductive health of women and girls in lower-income countries: is the FCDO doing enough post-pandemic?

Submission from MSI Reproductive Choices

Background

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. Last year we reached 21.1 million clients with sexual and reproductive healthcare. For further details about our work and impact please see: https://www.msichoices.org/media/4780/msis-2022-impact.pdf

MSI is proud to be a key partner in implementing UK government commitments to sexual and reproductive health and rights (SRHR), consistently delivering ground-breaking, rights-based programmes at scale, whilst providing results and value for money for the UK taxpayer.  

MSI and our consortium partners currently receive UK Aid to implement the UK’s flagship SRHR Women’s Integrated Sexual Health (WISH) Lot 1 Programme as well as implementing multi-year bilateral programmes in Pakistan (Delivering Accelerated Family Planning in Pakistan), Sierra Leone (Saving Lives II), Tanzania (Scaling up Family Planning), Uganda (Reducing High Fertility Rates and Improving SRH Outcomes) and Afghanistan (Supporting Afghanistan’s Basic Services).

Why support to SRHR should continue and increase?

Access to SRHR is foundational to many areas of global development, ending preventable deaths, supporting girls to stay in school, and providing women and girls with the freedom they need to succeed. The UK’s SRHR programmes in low-income countries have saved lives, reduced poverty, improved health and gender equality outcomes, as well as benefited the UK’s own security and economic partnerships. The UK’s strong legacy of leadership and commitment to SRHR has set the foundation for real progress over the last decade in terms of reducing maternal mortality, meeting the needs of communities in lower-income countries (e.g., with supplies, healthcare services, education, and information), and creating a more enabling environment to protect and support SRHR.

Over the last decade, awareness of SRHR - and its benefits - has increased significantly. In the same period, the number of women and girls reaching their reproductive years has increased to more than 1 billion in low and middle-income countries. As community awareness and need continue to rise, we have seen an unprecedented demand for our services. However, SRHR remains underfunded and in many places unavailable and we are particularly concerned about access for marginalised and excluded communities where services through the public sector are limited or highly stigmatised, for example for LGBT+ people and people living with a disability.

Evidence has consistently found that investing in SRHR is a development ‘best-buy’, contributing to numerous Sustainable Development Goals such as Gender Equality; No Poverty; and Health and Wellbeing. Every $1 invested in contraception generates over $8 in health and socio-economic gains, for example in 2022, MSI’s services saved an estimated $849 million in direct healthcare costs. However, despite this 257 million people who want modern contraception still don’t have access, and every year, an estimated 35 million people are forced to resort to unsafe abortion.

The global maternal mortality rate in 2020 was 223 per 100,000 live births and achieving the SDG target of a global rate below 70 by the year 2030 will require an annual rate of reduction of 11.6%, a rate that has rarely been achieved at the national level. However, the right medical interventions can prevent most maternal deaths, so this is possible with the right prioritisation and investment.

Therefore, our key recommendation to this inquiry is for the FCDO to reinstate its support to gender equality and ensure that an average spend of 4% of Overseas Development Assistance (ODA)[1] is allocated to comprehensive SRHR programming. To ensure the effective implementation of the new global Women and Girls strategy we recommend the continued funding of the Women’s Integrated Sexual Health (WISH) programme at the initial impactful level; that longer and more reliable funding agreements (minimum of 5 years) are established; that SRHR remains a clear and named priority in funding, policies, and diplomatic negotiations; and that the FCDO maintain their current level of support to UNFPA Supplies programme and continue to support and invest in civil society advocacy for domestic resource mobilisation.

How effective is the FCDO’s work on SRHR?

The WISH programme is one example of an effective SRHR programme integrating services and strengthening capacity across the national health system. Working initially across 27 countries in Africa and Asia, the programme delivers a comprehensive, integrated approach to ensuring equitable access to SRHR that prioritises the poorest and most underserved women and girls. It has achieved measurable results despite an increasingly challenging backdrop and since 2018 MSI and our consortium have:

• Averted 36,900 maternal deaths
• Avoided 3,854,500 unsafe abortions
• Reached over 6 million women and girls, including 1.4 million adolescents
• Supported over 300,000 women and girls to stay in school

For further information about how the WISH Programme has supported national efforts to improve SRHR please see: https://www.msichoices.org/media/4387/wish-report-sustainable-pathways-final-en.pdf

As a leading programme delivery partner, we welcome the FCDO’s view (as set out in the Women and Girls Strategy following engagement with civil society) that investment in SRHR is most effective when it meets the following criteria:

       A combination of multilateral and bilateral funding is available

       Investment is targeted at countries based on need not FCDO priorities

       Investment is allocated to programmes and projects which already exist and demonstrate effectiveness

       Decisions are based on engagement with civil society groups

       Different risk levels for potential grant recipients are acknowledged

       Allocations given to Women’s Rights Organisations (WROs) and established civil society groups complement each other

We would also suggest the following to improve the effectiveness of SRHR programmes:

• Ensuring extensive prior assessment of the role of other donors, the priorities and commitments of recipient governments, and the needs and the gaps of ministries of health.
• Intense and intentional consultation with major stakeholders at all stages of the programme cycle – including dialogue with communities, providers (public and private), professional associations and civil society groups.
• Clearly linking programmes to existing national commitments (e.g., FP2030) and national plans to ensure greater alignment and accountability.

Is the FCDO’s approach to sexual and reproductive health programming in lower-income countries sufficiently responsive to the needs of communities and how could the FCDO target the use of funding more effectively?

The global and funding context has become more challenging, unpredictable, and more interconnected. This coupled with the devastating impact of COVID-19 on health systems means that we need to be ever more focussed on reaching the most marginalised and ensuring impactful and inclusive programming. To be fully responsive to the needs of communities, including through the UK’s new SRHR programme, we encourage a continued focus on comprehensive SRHR (as defined by the Guttmacher-Lancet Commission) including support for abortion services and comprehensive sexuality education; to engage with and intentionally support the most marginalised groups and communities (e.g. the poorest, adolescents, people with disabilities and fragile and conflict affected settings); focus on scaling up access to a wider range of contraceptive methods bearing in mind that often the most effective longer lasting methods are currently unavailable; and prioritising support to advocacy to both remove the unnecessary legal and policy barriers that restrict access (e.g. the need to be married to access contraception; for your life to be at risk in order to access abortion), and to ensure sufficient domestic resourcing for SRHR information and services.

In terms of the inquiry’s question on how effective the FCDO’s work has been, our key concern is the cuts that have been made to existing programmes. Taking the MSI component of WISH as an example the programme budget from 2019/20 to 2023/24 has been cut by 79%. These cuts have deeply undermined the ability of this ground-breaking programme to achieve transformational and sustainable change to services and policies. The impact of the cuts is multifaceted, for example:

• In 2019 MSI’s WISH programme reached more than 2 million clients but in 2023 we will only reach an estimated 224,000 clients.
• As a result of year-on-year budget decreases we will see a 90% drop in the number of youth clients reached with lifesaving services through this programme. This means that an estimated 385,000 adolescents in 2022/23 will not access the services that were available in 2019/2020 - a wasted opportunity for the next generation of young people.
• Nigeria and Ethiopia have been some of the worst affected countries, a conscious decision by the FCDO to reduce funding in these countries. However, cuts have also been severe in FCDO WISH priority countries, for example a decrease of 75% in DRC and similar levels in Mali and Madagascar.
• WISH has closed programmes and services in 8 countries. The number of country programmes supported through WISH Lot 1 and for MSI under the Lot 2 reduced from 20 to 12 (6 for MSI and 2 for IPPF -Cote d’Ivoire and Cameroon) from 2019/2020 to 2023/24, a 40% reduction in the programme’s global footprint.

Impact Reduction 2019/202 to 2023/24

• Total clients reached – an estimated 89% drop from 2,080,000 to 224,900 (highest reduction in Nigeria, Mauritania, and Mali).
• Maternal death averted – an estimated drop from 8,800 to 1,100 (highest reduction in Nigeria, Ethiopia, and Mali).
• Unsafe abortion averted – an estimated drop from 969,000 to 116,600 (highest reduction in Mali and Ethiopia).
• Total adolescents reached – an estimated 90% reduction from 429,400 to 44,900.

Looking beyond the numbers these cuts have had serious implications not only for the morale of our teams but for the government, community and client relationships that are critical to our ability to provide services to marginalised women and girls living in the poorest communities. Throughout the programme’s implementation we have constantly been forced to make difficult decisions about what and where we deliver, for example closing services in some communities or not scaling-up tailored services for women and girls living with disabilities.

What has been particularly challenging is not just the reduction in budgets, but the numerous rounds of cuts often at the eleventh hour. This has increased insecurity and transaction costs for all involved (e.g., time spent rebudgeting, replanning, closing out and then scaling back up programmes so needing to recruit new providers and re-establish new partnerships), and undermined our ability to plan and develop longer-term strategies for sustainability. Whilst we know the UK’s ODA budget is currently under huge pressure and understand that hard choices need to be made, the abrupt and seemingly arbitrary nature of some of the cuts have harmed the UK’s reputation as a serious, reliable, and credible global player and interlocutor with both international and national stakeholders. Covid created exceptional circumstances but given our experience of managing this ‘flagship’ programme lessons need to be learnt so that future programmes are not similarly impacted and that their longer-term goals towards sustainability and national ownership are not undermined.

Does the FCDO’s new global Women and Girls strategy sufficiently address sexual and reproductive health?

MSI welcomes the FCDO’s new global Women and Girls strategy, its prioritisation of SRHR and recognition of the critical role that SRHR plays in empowering women and girls. We particularly support the specific references to safe abortion, the recognition of the global rollbacks on rights, the intersectional lens, and the support for advocacy in the new global Women and Girls strategy. SRHR underpins all the Three Es, and as such, should not be confined to a single pillar. We recognise that the FCDO has placed SRHR under the ‘Empowerment’ partly for simplicity of communication, but we would encourage the FCDO to be more explicit in acknowledging the size and scope of the ‘empowerment’ pillar, which in addition to SRHR incorporates several areas previously recognised as standalone pillars.

There is currently a disconnect between the current political and financial support for SRHR and the laudable goals of the strategy will not be achieved without dedicated SRHR investment to match. We would like to see a clear delivery plan with milestones and accompanying budgets, in addition to hearing more about how the FCDO will consult with partners and civil society in its development, implementation and monitoring. One area which we think could be particularly strengthened under this strategy and where the former FCO and DFID can be ‘more than the sum of its parts’ is the involvement of UK embassies, High Commissions and other FCDO international offices in supporting SRHR through diplomatic negotiations and support to SRHR civil society organisations (for example by offering safe convening spaces, funding advocacy, or supporting policy change through soft diplomacy).

Whilst SRHR is predominantly situated within the Women and Girls Strategy, SRHR is also a crucial area underpinning many of the UK’s foreign policy and international development goals, including economic resilience and climate change. There is increasing evidence that gender-responsive climate action is foundational to climate change adaptation and resilience, and we therefore recommend that all UK government-funded climate mechanisms expressly encourage climate adaptation and/or resilience programmes with a direct focus on removing barriers to SRHR as a cost effective and transformational response to gender inequality and the climate crisis.

Considering the growing, well-funded and sophisticated anti-SRHR opposition the UK’s continued global leadership in this area is crucial. Given this increased hostility, holding the line on existing commitments in international negotiations and at global fora is crucial for countering these groups and supports the ability of MSI and our partners to operate and to continue to advocate to uphold reproductive choice. For example last year at the UN, 71 countries joined a UK-led statement on respecting the bodily autonomy of women and girls to advance gender equality[2], while the political declaration on Conflict Related Sexual Violence (CRSV) following the ‘Preventing Sexual Violence in Conflict Initiative’ conference recognised that promoting and defending comprehensive SRHR is key to tackling CRSV, and reaffirmed the UK’s commitment to ensuring access to comprehensive SRHR at the outset and throughout crises.[3] Given the chilling reversal of the right to abortion in the US and the persistent stigma around SRHR, leadership of this nature helps providers, partners and grassroots CSO advocates to remain resilient, to progress advocacy campaigns to expand reproductive choice, and to hold national governments to account for commitments made.

As a key recipient of FCDO funding and a development partner to the UK government we look forward to continuing to engage with the IDC through this inquiry and as the Women and Girls strategy moves into the implementation phase.