Domestic resource mobilization

This message board is for discussions on lessons learned and best practices in mobilizing domestic resources for family planning.

Published Date: 
Wednesday, March 27, 2019


Questions from webinar on catalyzing a trend shift in domestic financing for family planning

The following questions came up during today’s webinar on catalyzing a trend shift in domestic financing for family planning (during which the FP2020 Partnership; the PEPFAR Sustainable Financing Initiative, led by USAID; the Gates-funded “Challenge Initiative;” and Health Policy Plus presented):


1. FP2020 noted in their presentation that, among FP2020’s 37 commitment-making countries, 92% of all domestic FP government expenditures come from lower-middle income countries (LMICs) with the remaining 8% from lower-income countries (LICs). What explains this spectacular difference?


2. In countries supported by the USAID Sustainable Financing Initiative (SFI), what has SFI seen in terms of increases in government allocations to Social Health Insurance (SHI) schemes being accompanied/followed by decreases in governments allocations to other health sector programs, thereby offsetting a net positive impact on domestic resource mobilization (DRM)?


3. If FP commodities are being provided for free by donors/partners, does it still make sense to explore integrating FP services into insurance benefits packages? If so, how do you motivate policy makers to integrate these services into benefits packages when donors continue to cover commodity costs and there isn’t evidence at country level that donor funding is going down in the near future? How do you rationalize this conundrum to policy makers?


4. How do the Health Policy Plus (HP+) catalytic investments framework and case studies from SFI and The Challenge Initiative (TCI) address sustainable domestic investment in demand generation for FP?


5. To what extent is the private sector engaged in TCI’s efforts? How does TCI support governments, CSOs, and the private sector to hold governments accountable to the FP financing commitments they make?


6. We’ve seen some success in co-financing models at the national level under Gavi and Global fund – should similar mechanisms be considered for family planning?


When providing a response, please note the relevant question number(s) in your reply.

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Arin and Elise

Question 3 – this is a great question and one that we’ve heard and talked about often in other family planning financing forums. I wrote a blog related to this last year:


The answer is yes, FP should be integrated into insurance benefits packages. Demand for FP continues to grow, economies continue to develop and donor funding is stagnating or even decreasing in some cases. Given this, we would expect to see the government take more responsibility in financing the health sector including family planning and not relying solely on donor support. One of the ways to finance family planning is through insurance. Many LMICs have or are developing national or social health insurance schemes which have the potential to cover a significant proportion of the population over time, reducing out-of-pocket spending and increasing financial protection. The cost of integrating family planning into benefit packages is minimal compared to the potential impact. In many LMICs the cost of FP commodities and contraceptives is almost completely funded by donors and therefore contraceptives are often free to the FP user at the point of care. If FP is integrated into a health insurance scheme, member contributions can help cover the actual cost of procuring contraceptives and providing the service. This would allow the government to reduce its dependence on donors while simultaneously maximizing their limited resources by allowing the insurance member contributions to help cover all or part of the cost. Now there are challenges…it takes time for insurance companies to be able to fund commodities and there is a challenge of getting insurance schemes access to pooled funding prices which are lower than market value. But as we have seen from several countries, such as Vietnam, it is possible and standard for insurance to pay for commodities. This is not a process that will happen overnight, it takes time and planning. Advocates should demonstrate the increasing need for family planning – which relates to increased cost – compared to the stagnating donor contributions which will show that sooner than later, there will be a gap and unless the government takes actions years in advance so they are prepared to cover that gap immediately, it could leave users without access to family planning.

Question 4 – The catalytic investments framework helps the user breakdown the question by first asking what are the barriers to funding demand generation. Often barriers to demand generation include cultural or social barriers such as religious or pronatalist beliefs. Addressing these barriers requires advocacy and community engagement at a local level but also among key policy and decision makers. We’ve seen that as a result of advocacy, policy is revised to provide universal access to family planning services and information. In some cases, such as in Madagascar, the policy goes as far as requiring the government to fund demand generation activities. Demand generation can also be integrated across health areas as there is a lot of shared targeting for RMNCH/Nutrition; and this would be great for co-funding from subnational governments, and it needs to be included in subnational government planning and budgeting. As a cross-cutting theme of the framework, evidence generation may be needed to estimate the funding needed for demand generation. The framework walks through this approach so the user can identify how to address the barriers directly related to the specific country context.

TCI might be able to provide some examples of how they've seen demand generation supported at the local level. 

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Question 6- yes, we discuss co-financing as a type of catalytic investment in the framework document. Co-financing requirements is one way to motivate governments to further prioritize the health sector. However the effectiveness of co-financing models on domestic resource mobilization depends on the accountability mechanisms in place to ensure commitments turn into actual spending and that spending is monitored. Political will is also essential to see a follow through on commitments and mobilization of domestic resources. Lastly, in a resource strained environment with goals of progressing towards UHC and with the additional pressure of COVID-19, we should expect to see less vertical funding efforts and a further push to support the whole health system. It is stakeholders’ jobs to ensure family planning is included and not left behind in this approach.

Many thanks for Q1 above. The full detail for the 2017 domestic expenditures that I was summarising can be seen here There are 37 countries that have validated domestic FP expenditures and you can see this is dominated by several large LMICs including Bangladesh, India, Indonesia, Pakistan and the Philippines. As you can see a number of LICs are expending substantial domestic resources on their FP programmes despite the constrained fiscal space that many are operating within. Domestic financing commitments to FP2020 varied in their specificity and ambition. We are currently developing commitment guidance for the next family planning partnership including for country financing commitments and so please do be in touch with me to provide input on this guidance.

What recommendations do we have for countries embarking on a transition from external financing for FP?

Increasingly, donors are focused on working toward a transition from development assistance and toward sustainability. (USAID has defined "sustainability" as “the capacity of a host country entity to achieve long-term success and stability and to serve its own clients and consumers without reducing the quality of services" after development assistance ends.)


When working to increase domestic financing of family planning and preparing for a successful transition from external financing, what best practices or recommendations should we consider?

Suzy, this topic should spark some interesting discussion! Thanks for raising it. 


In the family planning space, some donor-supported programs such as those in Latin America and the Caribbean (LAC) supported by USAID, matured into stable programs and transitioned financing responsibility to domestic governments. Some countries have also experienced transition from other donors, such as Gavi and Global Fund, which has increased documentation of lessons learned and recommendations on successful transition.


Based on these studies, several key steps are important to successful transition from external FP financing:


1. An assessment of readiness to transition from external financing, identifying key strengths in the country’s capacity to assume FP financing and service delivery responsibilities, and areas that need to be improved prior to transition. Proper planning for transition and sustainability is crucial.


For example, USAID’s graduation planning for FP has focused on six main areas:

 - contraceptive product security

  - advocacy, policy dialogue, and political commitment in contraceptive financing and in support of the overall FP program

  - data for decision-making

  - equity

  - health reform

  - institutional capability and human resource development


 Evidence on successful transition from other donor financing (e.g. Gavi and Global Fund) highlights the need to address critical gaps in institutional capacities in regulation, procurement, supply chain, and data systems.


2. Reaching consensus on a graduation strategy or transition plan timeline, components, pace/scale of donor withdrawal, and any post-transition support. Risks to sustainability from the transition readiness assessment must be addressed in a transition plan, with potential incentives to mitigate them. The transition plan should include buy-in from all stakeholders, including the public and private sector, NGOs, commercial sector, other donors, and other advocacy groups. It is recommended that transition is divided into phases to allow time for development and institutionalization of activities. Evidence from transition in LAC countries indicates a timeline of 2-5 years is appropriate, with potential continuing support for specific activities for a longer period of time.


3. An accountability mechanism should be developed between external donors and national stakeholders, alongside monitoring of transition. Monitoring and evaluation should ideally begin pre-transition, continue during transition (through the use of mid-term evaluations to course correct as needed), and beyond completion of transition to ensure institutionalization and sustained, quality services and outcomes.


What are some other key recommendations for countries to consider as they increase ownership of family planning financing?

Developing financing strategies for priority health programs

HP+ has supported the government of Ethiopia to investigate and develop options for the long-term, sustainable financing of key health areas. In family planning, HP+ examined the financing impact of integrating family planning services into the country’s community-based health insurance scheme and proposed social health insurance scheme. We also looked at how an increased role for the private sector would reduce the government’s resource needs from family planning. More recently, HP+ supported the development of a national HIV Domestic Resource Mobilization Strategy which aims to develop and strengthen both innovative and more traditional mechanisms for health financing. While focused on HIV, this strategy will increase fiscal space for health overall and contribute to more sustainable funding for integrated programs, like family planning. Are you familiar with any similar financing strategies being developed for family planning or other priority health areas?

HP+ is developing a framework for identifying catalytic investment opportunities to mobilize domestic resources for family planning. The HIV community has been using catalytic investments as a way to incentivize investment in HIV, for example through USAID/PEPFAR's Sustainable Financing Initiative, but it's newer in the family planning space. The Challenge Initiative for example is working at the sub-national level, offering matching grants to city governments that make an increased investment in family planning. After reviewing experiences from countries that have transitioned away from donor funding for family planning and successes in mobilizing resources for HIV, there are several different kinds of catalytic investments including advocacy, analysis, capacity development, policy development and financing (such as co-financing or matching grants). We are putting together a guide for countries to use to identify the appropriate catalytic investments for them based on the country context that we hope will help country governments and development partners prioritize investments. Stay tuned!