Moving forward to achieve the Sustainable Development Goals: How do we secure sustainable investments for family planning? [version 1; peer review: 1 approved, 1 approved with reservations]

Evidence demonstrates how rights-based family planning (FP) brings transformational benefits to women, families, communities and countries. Investing in FP is not only a human rights issue, but also a key catalytic factor for countries to achieve the Sustainable Development Goals (SDGs). Sustainable and equitable access to FP has a tremendous socioeconomic impact and boosts synergistic efforts to reduce poverty, achieve food security and improved nutrition, save lives and improve health and well-being, improve women’s and girls’ education, advance gender equality and empowerment, mitigate the effects of access to water and sanitation, reduce the impact on health of climate change, and contribute to economic growth and social inclusion. Nevertheless, while the benefits are realized across many other sectors, the burden of financing for FP is born predominantly by the health sector. Although there have been several attempts to integrate FP into other sectors’ initiatives, the results have not yet been fully systematized or scaled up. This open letter calls for a new approach to broaden the attention of different sectors to invest in FP as a catalytic intervention to achieve the SDGs. Using the UNFPA Conceptual Framework for Sustainable Financing for Family Planning , we will highlight elements to be considered by development actors in shaping national, regional and global actions. By exploring new funding sources and mechanisms to increase investments in FP, maximizing efficiency, and overall, revamping FP beyond the health sector, we intend to expand the reach of the discussions across non-traditional actors, underscoring the need to increase efforts towards guaranteeing universal health access for all as a main contributor to achieve the 2030 agenda


The need to secure sustainable investments in family planning
Reproductive health, including family planning (FP), is considered a cornerstone for development and one of the best development buys: according to the Copenhagen Consensus, FP is the investment area with the highest return on investment among the development sector including food security, nutrition and education 1 .
Despite the very strong financial, developmental, social and economic arguments in favour of FP, it continues to be an underfunded priority and its resonance in the financing community continues to be relatively low at both international and national levels.Funding and effective programmes for these key development interventions are insufficient.While as of 2017, nearly 700 million women and adolescent girls in developing countries were using modern contraceptives, 214 million women aged 15-49 in developing regions who want to avoid pregnancy were not using a modern contraceptive method 2 .Meeting their contraceptive consumption needs over the next three years will require $8.45 billion 3 .
While it is clear that insufficient resources limit the availability and quality of FP services, and overreliance on outof-pocket payments creates barriers to access and creates and perpetuates inequities, donor funding can be unpredictable and unsustained and often comes with specific conditions that might not align with country priorities 4,5 .And, while advocacy efforts to increase domestic resource mobilization at the national level are gaining strength, commitments are not always expressed in additional budget allocation for FP, or budget expenditure is not always realized.
Looking for more sustainable investments in FP, the international community has recently focused its efforts in increasing domestic resource mobilization within the health budget, where the fiscal space is usually limited, and many competing priorities, including humanitarian crisis and conflicts and political instability, limit these efforts.

Family planning as a key condition for achieving the SDGs
FP, as an integral part of sexual and reproductive health and rights, has long been recognized as essential for women and girls' overall health and empowerment 6 .Yet, despite the welldemonstrated role of FP as a development best-buy, advocacy efforts prior to the twenty-first century primarily emphasized the role of FP in saving lives rather than its broader socioeconomic benefits [7][8][9][10] .Further, the transformational benefits that voluntary FP brings to entire communities have been established in many areas; development initiatives now emphasize clear but multiple targets, as per the United Nations' Millennium Development Goals (MDGs) and the Sustainable Development Goals (SDGs) agenda.
FP has been a catalytic and synergic factor in reducing many inequalities; there is a broad list of issues that FP impacts directly and many SDGs achievements to which it contributes 11 .Moreover, in recent years, the international community has highlighted its importance and prioritized this intervention through many important threads including the Global Strategy for Women's and Children's Health, the Family Planning 2020 Movement, and the United Nations Commission on Life Saving Commodities for Women and Children.
Furthermore, discussions around the role of FP as a critical part of achieving many of the SDGs have captured the attention of not only the health sector, but also the broader development community.In a recent analysis developed by HP+ using the SDG modelling tool in Malawi, projected scenarios demonstrated that: "If Malawi surpasses its family planning goal, the number of people living below the poverty line could shrink by 25 per cent, food insecurity could decrease by half, and income growth rate could increase by 77 per cent, among other beneficial outcomes, boosting the country's prospects for achieving the SDGs" 12 .
It is clear that the burden of financing FP has been relying in the health sector alone while the benefits of investing in FP are spread across many other sectors.
Although integration of FP with other development initiatives has been explored in many ways during recent years, particularly in the fields of nutrition and food security, climate change and environmental health, education, water and sanitation and microfinancing among others, it still remains unclear how to translate this programmatic integration into budgetary integration during development of programmes, and moreover, how to advocate among all these sectors to integrate these efforts into their budgets.
Inclusion of FP in climate change and resilience initiatives, for instance, has been timid and limited despite the growing interest of donors in investing in this sector; in a recent study commissioned by Population Matters it was found that family planning is the most cost-effective method of abating carbon emissions costing only $1.1 per tonne.Studies invariably show that family planning is highly cost-effective compared with other emission abatement strategies 13 .
Recognizing the resource constraints in the evolving landscape and the need for financial sustainability of development programmes, UNFPA is exploring, innovating and shaping its corporate financing architecture and those of its programmes, inclusive of the UNFPA Supplies thematic fund, to ensure an evidence-based, responsive pathway to sustainability.The UNFPA "Conceptual Framework on Sustainable Financing for Family Planning" build on lessons learned from its country and global presence and defines three main pillars to secure sustainable investments in FP: (1) maximizing the effectiveness and efficiency of FP programmes through a health system strengthening approach; (2) revamping FP as a multisectoral investment priority in order to achieve the SDGs; (3) expanding funding sources with a focus on domestic resource mobilization.
The conceptual framework also identifies a series of elements to be considered by development partners to shape action at all levels.Among the key elements described in the framework are: (A) defining the need; (B) defining the financing and system delivery gaps; (C) catalysing an evidence-based tailored package of high impact practices and cost-effective strategies required to reach long-term sustainability with domestic resources; (D) integrating FP into multisectoral investments; (E) applying a differentiated country categorization approach with transition models; (F) advancing innovative financing models that crowd-in and secure additional domestic resources; (G) negotiated accountability frameworks such as country compacts situated within national oversight mechanisms that detail commitments of all actors; (H) strengthening knowledge management systems and practices to ensure policy-and programme-relevant information are generated and used for decision-making.
This paper explores each of these elements and summarizes multiple experiences across different regions.
Maximizing the effectiveness and efficiency of FP programmes through a health system strengthening approach Defining the need: Linking needs with budget allocations In Uruguay, up until 2010 public sector contraceptive procurement appropriations came from funds that remained in the budget towards the end of each year, where if they were unused could be allocated to general revenue for discretionary functions.During the first months of the year, although it was necessary to acquire essential supplies, procurement varied greatly, being limited by lack of budget and fluctuating amounts left from the previous financial year, and forecasting of supplies needed was not possible, leading to overstocking in some cases.
A dramatic change occurred in 2010, with introduction by the Uruguayan Government of a budget line item for contraceptive procurement within the national budget, as well as improvement of the logistics system and to forecasting.The laws that enacted budgetary allocations also made it possible for procurement to be increasingly based on the calculation of estimated need.Although the purchase volume decreased, it was a positive indicator because it reflected the current needs.
Since 2010, Uruguay's Ministry of Health (MOH) and UNFPA have collaborated to facilitate prequalified health commodity procurement at reduced prices compared with local purchases, through agreements or co-financing agreements.This collaboration has permitted significant cost savings in commodity purchasing.As an example, the single purchase of three commodities resulted in savings of more than US$ 1 million 14 .
Defining the financing and system delivery gaps: Building on policy changes, strengthening the health system In Panama, the MOH developed a strategy to undertake a diagnostic study and plan to address deficiencies in forecasting, procurement, storage, distribution, dispensation and use.The MOH alerted health-care facilities at all levels that information collection and record keeping on health commodities was critical to improving the functioning of the system and the experience of clients.The MOH established distance learning modules on logistics management and maintaining the cold chain, and regional health managers also received capacitybuilding on forecasting and logistics management.To build ownership and custodial responsibility, the Government financed and managed the process with technical support from external actors, including PAHO/WHO and UNFPA.The decision to apply the process to all health commodities, not just contraceptives, made for a more complex process, but also resulted in a larger impact on health.Improvements have reduced unit costs, made procurement more efficient.One of the innovations was an Internet portal for procurement that is open for public scrutiny, making the process also more transparent.In January 2013, the MOH gained permission to hold reverse auctions through the portal, which allows bidders to compete for sale of commodities at the lowest price 15 .
Catalysing an evidence-based tailored package of highimpact and cost-effective strategies required to reach longterm sustainability with domestic resources: building on the reproductive health commodity security national strategy In 2010, the Government of Mexico  20 .

Sahel Women's Empowerment and Demographic Dividend.
The Sahel Women's Empowerment and Demographic Dividend (SWEDD) regional initiative, launched in 2015, the result of a joint response by the United Nations and the World Bank Group, is a response to a call by the presidents of the six Sahel countries: Burkina Faso, Chad, Côte d'Ivoire, Mali, Mauritania and Niger.The overall goal of the project is to accelerate the demographic transition, to spur the demographic dividend, and to reduce gender inequality in the Sahel region.
The project identified three key areas of intervention: the creation of demand for reproductive, maternal and child health and nutrition (RMNCHN) services and commodities through social and behavioural change; access and the availability of RMNCHN services and commodities and qualified health personnel; and the support of policy development tied to the demographic dividend.
As a result of this initiative, a regional supply mechanism to obtain lower pricing for quality reproductive health commodities was developed, as well a financial arrangement that included a financing advance from the World Bank relevant partnerships to support the countries during the project's design, implementation, and overall governance.

Expanding the funding sources with a focus on domestic resource mobilization
While With the reduction of contraceptive donations from the international donor community, UNFPA increased advocacy efforts in various areas, among them the Health Sector Roundtable and FONSALUD, so that the Government would increase public funding for the purchase of modern contraceptives.
The importance of including the FONSALUD indicators is that they commit the MOH to monitor and track progress even though funds deposited through FONSALUD do not directly support each of the indicators.Progress is reported each year in the Annual Management Report.This has contributed to the increase in political and financial commitment for RHCS, which is evidenced by the increase in assignation of public funding for procurement of modern contraceptives.
This good practice provides a model for: (1) sustaining improvements made in the health system, such as the health commodities logistics system; and (2) ensuring the MOH is held accountable for improving citizen's health through the monitoring of common indicators.The collaborative effort has contributed to increasing the Nicaraguan Government's political and financial commitments to reproductive health commodities security (contraceptives), as evidenced by the increase in the Government's commitment of resources for health from US$ 227,500 in 2009 to $ 742,173 in 2013.
Similarly, faced with the end of donor support for contraceptives in Bolivia 23 , the MOH needed to generate resources to sell and purchase adequate supplies.In 2010, the MOH issued a ministerial resolution authorizing the transfer of UNFPA donated contraceptives to the Health Care Supplies Central Authority (CEASS) so that it could generate sufficient capital for a new revolving fund that would be used exclusively for the purchase of contraceptives.The authorization permitted transfers to CEASS so that it could monetize supplies through the Maternal and Child Health Universal Insurance Scheme (SUMI) to serve as start-up capital in a revolving fund dedicated for procurement of contraceptives.The dedicated contraceptive fund requires that municipal governments also establish a dedicated budget line item for the purchase of contraceptives.This new system allows for purchasing contraceptive commodities at scale, thus lowering prices, and ensuring the quality of the products through CEASS.
To undertake this ambitious strategy, the MOH partnered with the Departmental Health Services, social groups representing different sectors of Bolivian society, and municipal governments.The President issued a supreme decree allowing CEASS to solicit international bids for contraceptives directly.CEASS realized the first autonomous purchase at the end of 2014, which also allowed them to expand the range of contraceptive options available in Bolivia by including the female condom, emergency contraception and implants.
Continuing challenges include the need to strengthen the procurement skills of municipal governments, and to make the Bolivian population aware of the more reliable and greater variety of supply available in health services, which will hopefully contribute to increasing demand and satisfaction.
Increasing domestic resource mobilization through innovative financing, securing expenditure of budget allocation In 2005, the Universal and Equitable Access to Family Planning Services Law and its Integration in the National Reproductive Health Program in Guatemala ushered in a number of policy, regulatory, and administrative changes to reproductive health services.It guaranteed all Guatemalans access to contraceptives as a means of reducing maternal mortality.It created a commission comprising representatives of the Government, civil society, and universities to ensure that all health facilities, including hospitals have reproductive health services.The Law requires the Ministry of Education to provide all school-age children, beginning in primary school, with sexuality education.The law also guaranteed a process to buy, store and distribute modern contraceptives, along with a system for monitoring and evaluating its implementation.The law amended a previous law that allocated 15 per cent of alcohol taxes for the support of reproductive health and FP programmes so that 30 per cent of the allocation is earmarked for the purchase of contraceptives (Reyes, de la Cruz and Marin 2013).The law also ensured access to reproductive services by adolescents.Between 2002 and 2009, the contraceptive prevalence rate (CPR) increased from 43.3 per cent to 54.1 per cent, and nearly doubled from 23.8 per cent to 40.2 per cent for indigenous women; and unmet need for FP fell from 27 per cent to 20.8 per cent in the same period.
However, this example also illustrates that securing funds is not always sufficient to ensure they are used for the intended expenditure: in Guatemala, between 2012 and 2015 only 64 per cent of funds earmarked for FP and reproductive health were executed.

Negotiated accountability frameworks such as country compacts situated within national oversight mechanisms that detail commitments of all actors
Capitalizing on international commitments.In Sierra Leone, UNFPA engaged in advocacy efforts with other stakeholders aimed at sensitizing top Government policymakers including the Minister of Finance and the Minister of Health on the need to increase domestic fund allocation and release of funds for FP.Specifically, during the 2017 Family Planning Summit, through these advocacy efforts, the Government committed to using Le1 billion (US$136,054) for the domestic procurement of FP commodities out of a total of Le17 billion ($2,312,925; some 5.8 per cent) allocated for the procurement of drugs and supplies.The Government also committed to diversify its resource base for FP through providing a budget line and allocating 1 per cent of the health budget.In 2016, spending on FP from the national health budget was 1.28 per cent.
Later in 2017, UNFPA mobilized domestic resources through the DFID State Level Programme and committed US$700,000 to procure FP commodities for the national FP programme.This amount, complemented the resources provided through UNFPA Supplies, resulting in a UNFPA total donation of reproductive health commodities in 2017 of approximately $3 million.
Strengthening knowledge management systems and practices to ensure policy and programme-relevant information are generated and used for decision-making Making the case for increased domestic resource mobilization through evidence generation.In Myanmar, the increase in domestic commitment follows advocacy using data on the financial gap for FP, focusing on the Ministry of Health and Sports UNFPA presented findings from the Netherlands Interdisciplinary Demographic Institute survey on FP spending in Myanmar compared against the FP costed implementation plan: as an FP2020 commitment-making country, Myanmar's expenditure on family planning from government domestic budget is reported annually.Subsequently, the Government increased its budget for procurement of contraceptives by a factor of five.This increase is noteworthy in a country that allocates only 3.65 per cent of its total budget to health, which is very low by global and regional standards.Most households must pay out-of-pocket for health.A similar approach has been used in Mongolia following a series of assessments showing that during 2016-2020, expenditures on contraceptive commodities should reach an overall amount of US$2.33 million.The costs of spending will be offset greatly by the returns: this investment is estimated to generate savings of US$7.33 million in averted health-care costs in 2017-2020 24 .

Conclusions
Sustained and equitable access to FP has a tremendous socioeconomic impact and boosts synergistic efforts to reduce poverty; achieve food security and improved nutrition, save lives and improve health and well-being, improve women's and girls' education, advance gender equality and empowerment, mitigate effects on access to water and sanitation, reduce climate change impact on health and contribute to economic growth and social inclusion, among other benefits.
While FP is a catalytic factor in achieving SDG targets across multiple sectors, the burden of financing is usually confined to the health sector.Positioning FP as one of the most cost-effective interventions to achieve the SDGs should be discussed and borne by the development community and not only within the health sector.Advocacy and policy changes that prioritize FP and expand the funding sources for future investment across new and different actors, including the private sector are urgent and critical.
The current $8.45 billion funding gap does not reflect the inequities in accessing FP by the poorest.While securing to close the gap, the FP community should also focus its efforts in reducing those inequities and improving financial risk protection under a rights-based approach.
A financial sustainability roadmap should be an integral part of every FP programme and it should define clear timelines according to the country context and fiscal space planning opportunities regardless of the maturity of the programme in terms of financial sustainability.
Evidence generation is critical to inform policy discussions among key stakeholders.Evidence-based decision-making supported by cost-benefit analysis, business cases, policy briefs etc. contribute to building the case for investing in FP and enabling the environment for increased domestic resource mobilization.Understanding the fiscal space opportunities, assessing country readiness and applying a tailored long-term transition plan is important in defining clear goals and secure stable and clear donor support to the process.
Maximizing the effectiveness and efficiency of FP programmes through a health system strengthening approach is indispensable.Building and strengthening local capacities to manage effective FP programmes in an efficient way is key to sustain investments over the years.
Strong advocacy to increase political will and commitment is needed throughout all phases of the sustainability roadmap, including after the transition process.
Collaboration across and within different sectors and partners is crucial in order to align funding streams into common priorities.Joint planning and monitoring and evaluation is also indispensable to correct the course of the process.Even after a country has successfully transitioned to a sustainable approach, it is important to track progress over the years to maintain the gains and secure efficiency in budgetary execution.

Open Peer Review
Current Peer Review Status:  Family planning provides a range of economic, social and cultural benefits to communities and has been shown in many studies to be highly cost effective and a worthwhile investment where the benefits far outweigh the costs.However as Addico, Greaney and Lacayo argue, the benefits extend beyond the health sector narrowly defined, enabling a greater level of participation by girls and women in education and the workforce.These demographic dividend benefits contribute to greater rates of economic growth and improved living standards.The authors argue that family planning resources should therefore not be restricted to the health budget alone but have a stand alone status within whole of government planning.They provide a number of examples of how governments are addressing this issue.Family planning is also peculiarly subject to vagaries of funding from donors for cultural, religious or ideological reasons.As funding from traditional sources has decreased in importance and many countries experience very tight fiscal spaces, it has become important to identify new funding sources and mechanisms.Perhaps the authors could expand a little on novel source of funding such as social impact bonds and other mechanism discussed for instance by Clinton and Sridhar (2017) 1  Reviewer Expertise: Health economics I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.

Suneeta Sharma
Palladium, Washington, DC, USA In the beginning, the Authors make a very strong case that countries should invest in FP.They also call for a multisectoral response.It is a very important point.I become interested and curious to learn about different strategies used in countries to mobilize a multisectoral response and domestic resources for FP.Most of the examples included in this Open Letter are UNFPA examples of mobilizing funding for FP commodities within the health sector.These example didn't demonstrate a multisectoral response.The letter didn't include other examples and differing views.The examples didn't demonstrate efforts to mobilize a multisectoral response.The letter can be strengthened by including differing examples of mobilizing a multisectoral response and funding.The letter should provide actionable recommendations.Is the rationale for the Open Letter provided in sufficient detail?Yes Does the article adequately reference differing views and opinions?No Are all factual statements correct, and are statements and arguments made adequately supported by citations?Partly Is the Open Letter written in accessible language?Yes Where applicable, are recommendations and next steps explained clearly for others to follow?Partly and the Brookings Institution (2017) 2 .Partly Are all factual statements correct, and are statements and arguments made adequately supported by citations?Yes Is the Open Letter written in accessible language?Yes Where applicable, are recommendations and next steps explained clearly for others to follow?Yes Competing Interests: No competing interests were disclosed.

Central Africa Forest Initiative/Reducing Emissions from Deforestation and Forest Degradation Initiative
contraception and up to 87 per cent for oral hormonal contraception.Overall savings in procurement reported were 47.73 per cent (USD$ 3.97 million).
18initiated revision of the national reproductive health commodity security (RHCS) strategy, while simultaneously conducting a midterm evaluation of the UNFPA country programme.With the participation of other state actors, such as the National Council for Population and the Foreign Ministry, a new technical committee was established that developed an action plan to implement the RHCS strategy across five action areas: (1) coordination of strategic actors; (2) political outreach and advocacy; (3) RHCS capacitybuilding; (4) research and systematization of evidence; and (5) coordinated procurement.The process was designed to build local ownership and accountability, while transitioning UNFPA's role from implementer to technical adviser.uniform,resulting in significant cost savings.The process has also strengthened the capacity of the National Center for Gender Equality and Reproductive Health (CNEGSR) to coordinate and regulate the roles of other federal and state agencies working on FP in order to maintain a more regular supply across all 32 Mexican states.Savings fluctuated between 34 per cent for injectable hormonal .In 2013, the Government of Democratic Republic of Congo (DRC) publicly pledged commitment to FP at the Third International Conference on Family Planning in Addis Ababa, Ethiopia17. Shly thereafter, the Government launched the National Multisectoral Strategic Plan for Family Planning: 2014-202018.For the first time, in 2014 the Government paid US$ 300,000 for contraceptive procurement, and in December 2014, it also pledged an additional $2.5 million during the round-table at the Third National Conference on Repositioning Family Planning.
sexual reproductive health and rights remain a proven driver for sustainable development, across and within national contexts, enabling systems and the required domestic resources are under-prioritized within development programmes, especially in developing countries.Equitable access to quality contraception in many developing countries is substantially reliant on external funding from development partners; while the global financing landscape continues to be challenging due to varied and evolving global development financing needs, including-increasingly-to address humanitarian situations.This emerging global landscape underscores the need for shifts in approaches undertaken by national governments in financing development in any given context, especially as countries transition from lower to middle income status.They also established common indicators for monitoring health and gender and other social equity outcomes, as well as outputs related to efficiency and effectiveness of the financial performance and technical implementation of the plan.
agreed to pool their donor resources in the Nicaragua Health Fund (FONDOSALUD)-a consultative, negotiating, and consensus body-in support of the Nicaraguan MOH's multiyear institutional plan.Donor partner members make recommendations to the MOH's high level directorate on how to allocate financial resources to different health priorities in the country.
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