Exploring Current Trends and Opportunities in Domestic Resource Mobilization for Family Planning

Building on the strengths of country governments, institutions, and local communities while recognizing the importance of the local leadership and ownership have been of central importance to USAID programming. The USAID-funded Data for Impact (D4I) Associate Award of MEASURE Evaluation IV, is one initiative that is a testament to the local capacity strengthening approach that appreciates the existing capacities of local actors and strengths of local systems. Introducing our new blog series that highlights local research produced with support from the D4I project, ‘Going Local: Strengthening Local Capacity in General Local Data to Solve Local FP/RH Development Challenges.’

D4I supports countries that generate strong evidence for program and policy decision making by strengthening individual and organizational capacity to conduct high-quality research. One approach to this objective is to administer a small research grants program and collaborate with local researchers to:

1. Build and strengthen research capacity among local country organizations and agencies;
2. Address research gaps in family planning (FP) to inform policy and programmatic decision-making; and
3. Increase use of research findings by providing an opportunity for the data to be disseminated to and used by local stakeholders and decision makers.

Oftentimes, when articles are published about research they focus on the findings and the potential implications. However, if another country or program aims to implement a similar study, it is also equally important to document how they conducted the research, what was learned and what are the recommendations for others interested in doing similar research in their own context.

With this goal in mind, Knowledge SUCCESS has partnered with the D4I award program for a 4-part blog series featuring the tacit lessons and experiences of family planning and reproductive health (FP/RH) research conducted in four countries:

• Afghanistan: Analysis of 2018 Afghanistan Household Survey: Understanding Regional Variations in FP Use
• Bangladesh: Assessing the Readiness of Health Facilities for FP Services in Low-resource Settings: Insights from Nationally Representative Service Provision Assessment Surveys in 10 Countries
• Nepal: Appraisal of FP Commodities Management during the COVID-19 Crisis in Gandaki Province, Nepal
• Nigeria: Identifying Innovative Approaches to Increase Domestic Resource Mobilization and Financing Contributions for FP

In each post, Knowledge SUCCESS interviews a member of the research team of each country to highlight how the research addressed gaps in FP knowledge, how the research will contribute to improving FP programming in the country, lessons learned, and their recommendations for others interested in conducting similar research.

Descriptive analysis of financial data trends in Nigeria, specifically in Ebonyi State, painted a rather gloomy picture for family planning (FP). Dr. Chinyere Mbachu, Doctor at Health Policy Research Group, College of Medicine at the University of Nigeria, and co-author of this research noted that financing has begun to decline or even cease for reproductive health (RH), especially for FP. For this reason, those working in FP/RH have advocated for domestic resource mobilization, recognising the importance of states looking inward and taking ownership of funding for FP services and interventions. Nigeria’s basic health care delivery fund, which is funded by 1% of consolidated federal revenue, was cited as an innovative reform introduced at the federal level that should be replicated in the FP sector, ensuring effective use for consistent and efficient service delivery.

In this interview, Dr. Chinyere Mbachu elaborates on the relevance of domestic resource mobilization, its importance as it relates to FP, innovative strategies to improve it, and opportunities for Nigeria in FP financing, including increasing public spending on FP, among others.

Aïssatou Thioye: Could you talk about why you chose the topic of domestic resource mobilization and what the situation is in Nigeria?

Dr. Chinyere Mbachu : Our decision to look at domestic resource mobilization was because of the not-so-recent economic situation. With high inflation rates and the declining economy of the country – and indeed the rest of the world – spending on health, particularly funding from external sources, started declining. Some grants for health and particularly for FP actually stopped completely. Some governments, including Nigeria, also had to reduce spending and start prioritizing funding for health.

It became very important to look at domestic resource mobilization…Our work focused on subnational-level funding for family planning because in Nigeria, the FP program was actually completely funded through external sources and the federal government allocation to the states. The states would fund human resources for health, maybe pay salaries to the health workers, but not much more. When you look at the actual commodities—even logistics distribution of these commodities—those kinds of things were being funded externally from the [national government] coming through donor agencies. That’s the reason why we had to look at domestic resource mobilization because it became important that states begin to look inwards and take ownership for funding family planning services.

Aïssatou Thioye: What knowledge needs around the FP situation in your country has your research addressed?

Dr. Chinyere Mbachu: Yes, so not just how domestic resource mobilization can happen, but our research has also addressed the knowledge needs about the funding landscape for family planning in Nigeria. Existing studies or literature on the funding landscape for family planning in Nigeria have focused on the federal level. However, our study delved in and uncovered what is happening at the subnational level, which is a poorer picture than the federal level.The federal level is beautiful when you compare it with what is happening at the subnational level.

Aïssatou Thioye: What findings surprise you as a result of your research?

Dr Chinyere Mbachu: I think the most surprising thing for us was those years when nothing was released from the state government for family planning [2018 to 2020]. Nothing. No money was given to the family planning program. During those years, funding came from the federal government and from external donors. As soon as external donors completely pull out from funding family planning programs, it’s going to be a disaster for Ebonyi state. Even for those at the state level, it was surprising for them to see that their family planning program was being funded completely through external funding sources and short-lived programs, such as the “71 Million Lives” program, which was just a five-year program.

Aïssatou Thioye: What is the outlook for Nigeria in terms of increased government spending on family planning?

Dr. Chinyere Mbachu: I would say the outlook is grim, and I think that’s what we uncovered through our literature review and the rest of [the research]. Our study was a retrospective study looking at government spending on family planning, and trying to identify if there are innovative mechanisms for domestic resource mobilization. It was a retrospective of five years (2016-2020) and we discovered that, I think in [three to four] out of the five years, there was actually zero allocation to family planning commodities.

If you look at how the budget for the health sector is done, there was no line item separated for family planning. This means that there’s no plan. I mean, if there’s a line item and then you are having zero, then at least you have it in mind. It’s on the agenda. Maybe there’s no money to put there, or advocacy has not been done enough for funding to be put there. But there was no budget line. This shows that the outlook was actually grim. And then, like I said, the high dependence that we had on external funding, which we know is not predictable or reliable, all made the outlook not so good for Nigeria.

However, if we look at the outlook for increased government spending, I mean the 71 Million Lives program for results, a project that was implemented for five years in Nigeria through a World Bank grant that was given to the federal government, [we saw results]. And family planning was actually one of the priority services under the program, and one of the indicators for measuring performance under that program was contraceptive prevalence rate. The federal government disbursed this money to the state governments based on their performance on some indicators for health, which means that there’s potential. That money came to the federal government, as a grant, and then from the federal government to the state. So I don’t know how you would interpret this as an outlook for increased government spending [because] the program has ended, the funding has stopped.

Aïssatou Thioye: That’s interesting. And I think you have already started to discuss this point that I want to ask, so just if you want to add something on it, why is it important for Nigeria to improve domestic resource mobilization for family planning?

Dr. Chinyere Mbachu: Family planning is a proven effective tool for improving maternal, child, and infant health, reducing maternal and infant mortality and morbidity. And it’s not just that it’s an effective tool, but it’s also cost effective. We are not funding it as well as we should. So yes, there’s a need to improve domestic resource mobilization. Contraceptive prevalence rates are low and we are not yet anywhere close to the targets that we have set for ourselves as a country. That’s due to commodities not being available all year round, stock outs, etc. We know that there are some social issues that influence the optics of family planning services.

However, access to even these family planning services for those who want them is low. The unmet need for family planning is high. For these reasons, we need to fund family planning through domestic resource mobilization. It’s more reliable if the government is setting up outside funds for family planning, compared to when it relies on external funding.

Aïssatou Thioye: In the paper it is mentioned that a fiscal space assessment was conducted in Ebonyi state with an application of the roadmap for assessing fiscal space for health to identify the need for additional funding for office services in Ebonyi State. Why did you choose to focus your research on Ebonyi State alone? And what about the other states?

Dr. Chinyere Mbachu: The research group and the research team are located in Enugu State, in the southeastern part of Nigeria. And in the southeastern part of Nigeria, the Ebonyi state has the worst indicators for maternal health. The indicators are comparable to what we find in the northeast parts or northwest parts of the country where indicators are the poorest. So we actually have the poorest indicators for maternal health [in the southeastern part of Nigeria] when you are looking at contraceptive prevalence rates, maternal morbidity, maternal mortality, and teenage pregnancy rates…Also the funding was very small for us to expand.

Aïssatou Thioye: Let’s talk about methodology. The need for increased domestic resource mobilization has often been seen as a challenge to be addressed through advocacy. How did you decide that generating evidence through research would be a way to advance the issue?

Dr. Chinyere Mbachu: When you are asking policymakers to invest in a particular issue, we believe that the strongest tool that we could use to advance interest better is to generate evidence through research. The research we did [involved] these program managers and people from the government at the start, so they were initially engaged. And when we had collected our data and looked at this data, we presented it to them, and had them validate the data. All of that provided an opportunity for them to sit together and reflect on what we found and reflect on the way forward.

You could go anywhere and keep saying, “This is a problem, this is a problem.” But until you are able to provide evidence to show how much of a problem it is, and if nothing is done, this is what could happen. Providing evidence of what could happen if the issue is fixed, we believe that it will be more effective than just saying it is a problem.

Aïssatou Thioye: How did you access resources for your desk review? Can you talk more about it?

Dr. Chinyere Mbachu: For our desk review, the first activity was to engage, identify, or map and engage stakeholders through a consultation meeting that we had in the capital of Ebonyi State.

In a workshop we presented what we hoped to do, the research questions, and documents we needed, and had the stakeholders reflect and share ideas on how we could go about collecting the data. For example, if we needed to get financial documents, which types and from where, who in particular should we meet? [We also] had to look at the government and organizational websites to retrieve information.

Aïssatou Thioye: What were the main challenges in collecting and analyzing the data?

Dr. Chinyere Mbachu: The main challenge was missing data. I don’t know if I should call it missing data, but it was unavailable data. If we looked at a working paper, you know, there was some information that we needed, some lines or variables that we needed to report, and we couldn’t find data. Just the fact that I think there was a particular year and we kept looking and looking and we couldn’t find any data on expenditures for that particular year from the documents we had. So I think that was the main challenge that we encountered. We had conversations with the stakeholders to validate the data, and found that perhaps poor filing was the cause of the lack of data.

The experience with the research strengthened our research team’s capacity in fiscal space analysis.

Aïssatou Thioye: Over the past 5 years, excluding the 2020 budget, the budget allocation for health has gone from 2.7% to 3.2%. This, as you mention, is still below the Abuja recommendation of 15%. Can you explain why this is the case?

Dr. Chinyere Mbachu: This is a highly political question. The people who are in the best position to answer this question are those who are making these budgetary decisions. From my viewpoint, I don’t think that the politicians and policymakers actually view health as an investment yet, and that health actually does contribute to the state’s and the country’s economic growth and development. You wouldn’t put money in health until you begin to appreciate that it actually underlies your economic growth and development. As researchers, we need to start thinking about how to present health in terms of economic gain and economic losses. If I tell you health is worth this amount of money and will save you this amount of money or will earn you this amount of money, then maybe we can start getting them to understand why it’s important to make this 15% allocation.

Aïssatou Thioye: Budgetary allocations for family planning have been provided for in the state government’s budget for the last five years (2016-2020). However, releases were only made in 2016 and 2017, with very [small] amounts. Why has there been such a delay in releasing these amounts?

Dr. Chinyere Mbachu: We need to look inwards and see what we’re doing well and what we’re not doing so well as health program managers, for example, and how this is playing out in what is allocated to health and also what is actually released. In Nigeria, the health sector has, over the years, shown very poor absorptive capacity—meaning not all of the allocated money is used. I’m giving you a picture of what is happening at the federal level—we didn’t study what is happening in the states to that extent. But for the federal government, we learned there’s evidence to support that the absorptive capacity is very low. So if I give you this amount and you are not able to use it all, in the next year, I’m going to give you less. That could explain why the releases are not complete.

Aïssatou Thioye: What approaches have you identified for improving domestic resource mobilization and financing for family planning in Nigeria?

Dr. Chinyere Mbachu: One innovative health financing reform that Nigeria introduced at the federal level is the basic healthcare provision fund, which is actually financed by 1% of consolidated federal revenue. In other words, 1% of the government’s consolidated revenue goes to health. This is a lot of money that is coming to the health sector. So, this can also be done for family planning. State governments can actually go this route—go beyond the health budgets, look at a portion in the percentage of the consolidated revenue to the health sector and specifically to family planning and service delivery. It’s a lot of money that can go a long way for family planning if it’s used efficiently.

Aïssatou Thioye: How do you think your research can help programs in your country? And how do you see your research being used in the family planning field?

Dr. Chinyere Mbachu: The research we have done was at a small scale, in just one state. And I think there’s going to be value in looking at opportunities for domestic resource mobilization in the country as a whole, in other words, looking at all 36 states. It’s something that needs to be replicated across all the states because our study has uncovered some of the gaps in funding, not just amount, but how it’s been allocated. Beyond the technical aspects of it, it’s also uncovered some issues that the family planning program was having with getting more funds. Ebonyi State’s internal growth rate (IGR) has been unstable over the years. However, our findings revealed that from 2018 to 2020, the state generated higher actual revenue from taxation than the budgetary estimations made for tax revenue for those years. The current yearly IGR could be a source for additional fiscal space for health, and for FP programs, in particular. However, this revenue could be inadequate and will require a review of the state revenue generation mechanism to expand both tax and non-tax revenue generation. Improved IGR would cause the state’s fiscal space to expand and could filter down to the health sector and FP interventions.

We had an action planning workshop where the stakeholders — people from the Federal Ministry of Budget and Planning and people from the family planning department in the Federal Ministry of Health (FMOH)— had to discuss: “What do we need to do as a department or as a family planning program to get more funds from the state government?” And the participants from the Ministry of Budget and Planning gave them ideas and cues, and all of this actually went into the terms of reference that we developed in our paper and in our reporting.

I think for the whole country, this work should be replicated at a larger scale and even beyond family planning, looking at the whole reproductive health program in the country. We’ve been called to present our findings at a meeting for stakeholders, including funders in the family planning space, at the West African regional level. And our research has actually been used as a case study to facilitate a workshop of stakeholders in a domestic resource mobilization.

Aïssatou Thioye: In addition to workshops with key stakeholders, how do you plan to disseminate your findings for easy access and use by policymakers in Nigeria?

Dr. Chinyere Mbachu: We produce policy briefs of our work, which we have distributed through our website. When our working paper came out, we shared the link through our WhatsApp forum to all the groups that we belong to where policy makers are also part of the group. In addition to the working paper, we’ve actually written an academic paper for publication, which is undergoing review by a journal. So for the policymakers who are also academics who read journal articles, they will also have access to that once it’s ready. We have shared with our colleagues who facilitate the policymaker capacity building workshops and dialogues.

To explore more resources related to this interview series, don’t miss Data for Impact (D4I)’s FP insight collection, with further reading and materials shared by their staff in Afghanistan, Bangladesh, Nepal, Nigeria, and the U.S.