The reality:
Sexual Reproductive Health Rights (SRHR) are essential to achieving good health and well-being, but they remain unprioritized and unfunded by most low and middle income states as evidenced by poor SRHR indicators across maternal health, teenage preganancy, incidences of unsafe abortions, HIV/AIDs infection rates and sexual and gender based violence. There have been some improvements but SRHR programs have continued to be poorly prioritized by national governments in sub- Saharan Africa, national budgets for health continue to dwindle from year to year, without a dedicated vault for SRHR programs. Current trends show that individual consumers in developing countries pay more than anyone else for their own sexual and reproductive health, with extremely high out of pocket expenditures.
The implication of this is that low income and least developed countries such as Uganda, are heavily dependent on donors and other third parties to subsidize funding for these services. Uganda, for example, continues to grapple with persistently high maternal and newborn mortality rates, high incidences of unsafe abortion with 314,300 women risking their lives to induce unsafe abortion in 2013 alone, a high umnet need for family planning that stands at 28% and teenage preganancy rates are high at 25% (this situation has been made considerably worse since the onset of the COVID-19 pandaemic in early 2020).
Culture and religion have a major bearing on policy implementation and formulation. There are deeply entrenched attitudes and practices that relegate women in low income countries to struggle to access SRHR services. For example child marriages and polygamy deny women and girls adequate control over their bodies, high rates of sexual and gender-based violence and HIV related disease, particularly among adolescent girls, young LGBTI individuals and young sex workers, are a great cause for concern and in need of philanthropic investment.
The unpredictable and insufficient nature of funding for SRHR has for the longest time been one of the challenges facing the SRHR sector. Without dedicated national funding for the same, high reliance has been placed on funding from external sources that are restricted by the project life cycle process meaning that there are oten interruptions and/or stops to funding all together. This unpredictability makes it difficult for countries, and users of these health services to plan with certainty, it also means that the most vulnerable and those living on the margins of society are left behind due to access (geographic and economic) and affordability issues. This is because special health programs that are specifically designed with the unique needs of these individuals and communities are often implemented by non-profit organizations operating at national and community level- this tends to address the issue of acceptability of services.
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Where is the funding coming from?
What is clear is that the progress being made to improve the state of SRHR in Uganda and many low and Middle Income Countries in Sub Saharan Africa, is in large part due to funding from foreign States, philanthropic groups and individuals.
The US is one of the world’s biggest providers of foreign health assistance which makes its federal health policies and laws an important determinant of global health outcomes. For example the US abortion restrictions in US foreign aid including the Global Gag Rule, Helms Amendment have the effect of disrupting and in some cases altogether cutting off SRHR services both in the US but also in the least developed and poor countries like Uganda.
Another source of important health and particularly SRHR funding are private philanthropic agencies that have historically come in to supplement the national budgetary allocations for health that are often below the 15% threshold stipulated as committed by 189 Heads of State under the Abuja Declaration of 2001.
The dilemma
One of the emerging questions is whether current funding and investments are alive to the contemporary challenges that local nonprofits face. The ability of current funding trends and practices to be interdem with the funding needs of organizations and individuals working to advance SRHR in the local communities they serve is critical.
The COVID-19 pandemic has undoubtedly wreaked havoc on the lives of all human beings across the globe, however, for those that live on the margins of society, it has proved to be catastrophic as the development sector has faced unprecedented hardships.
These hardships have hit both funders and local and community organisations alike. This has meant that many organizations have had to scale back, cutting the amounts of funding that they are able to give. This effect has not only been felt by the local communities and nonprofits, but also by governments.
In a recent devastating development, the government of the United Kingdom announced an 85% funding cut to the United Nations Population Fund. The reduction from 154 million pounds committed for 2021, to actually providing only 23 million pounds will no doubt affect lives of women and girls across the globe but more so on low income countries like Uganda where UNFPA has historically subsidized the provision of life saving SRHR services including direct procurement of health care supplies. This cut by the UK government will also directly affect organizations like Marie Stopes International that have previously received funding from it.
The above, taken together with the fact that Uganda’s allocation to the health sector continues to dwindle with the sector having experienced a cut of 23.6% in the financial year 2021/2022. This trend has become characteristic of Uganda’s budgeting practice, irrespective of the population growth meaning increased numbers of persons seeking health care including sexual reproductive health services.
What needs to evolve?
The funding approaches for SRHR are already fast shifting, with some positive strides and some hurdles. The concerning trends and practices that play a role in the creation of uneven delivery of SRHR services are captured by the Guttmacher-Lancet Commission.
One of the aspects that needs to change is an over reliance on very formal systems for grant making. It is a known fact that the bigger and more formalized an organization is, does not necessarily correspond to the most effective approach in bringing the much needed services to groups on the ground. Especially where SRHR are concerned. The requirement for formal systems very often cuts off some of the most impactful organisations at the grassroots.
Philanthropy investment also needs to go beyond provision of services to investment in shifting societal attitudes, cultural biases and cost-benefit knowledge. Behavior change communications encourages the adoption of more progressive attitudes and behaviors in the communities that could go a long way in creating role models. Funders should therefore actively increase budgets towards communication within projects.
One practice that is increasingly receiving interest is participatory grantmaking, the practice of involving community members and other stakeholders in the grantmaking process. It can lead to different—and we would argue, better—decisions about who and what to fund. This allows communities themselves to decide where the funding is most needed.
Hiring right! Who do you have leading the programs? Especially for new organisations or organisations that seek to work in intersectional approaches, are these new hires/leaders/faces of these organizations part of the communities that they seek to serve. Granting and how these grants are managed is a practice that needs to evolve beyond representation into actual inclusion and equity practices.
Funding in unorthodox ways including giving funding to nascent organizations that have not yet attained legal personhood in instances where legal personhood may limit the impact of the work that these organizations are doing. Some organizations that operate in a nascent manner include those doing work that requires a behind the scenes approach, and those working with communities that face threats due to criminalization of the constituencies that these organizations serve. The protection that working within a legally registered entity provides cannot be dismissed, but this may also come with challenges of state over reach and control as we have seen in the recent past. Organizations have been shut down and their leaders incarcerated on the basis of flaunting legal provisions related to the legal status/personhood of these organizations and the corresponding legal obligations.
Conclusion
Underfunding is one of the key barriers to the realisation of universal access to SRHR in Uganda, this will necessitate a total shift in the way funding for these programs has been undertaken. Whether it be that governments prioritise the allocation of resources from the national resource envelope- these resources should be specifically earmarked for SRHR and key indicators beyond maternal and child health addressed to ensure that their impact is trackable. Being cognizant that the national government is not able to meet all funding requirements for delivery of SRHR services for all Ugandans. The role of other funders and the manner in which their funding is delivered needs to take into consideration the unique aspects of SRHR service delivery and uptake. Questions of how, where and when these services are delivered, being cognizant that there are myriad of factors that impact how these services are accessed by the snd user. These factors may include social, political, legal, human rights based - reproductive and gender justice issues should be at the core of the design and delivery of this funding.
