The shrinking reproductive health financing space and what indigenous organisations can do.
The UK announced cuts to funding for key SRHR components including HIV/AIDS and family planning in 2021. The funding for HIV/AIDS dipped by 85% (from GBP 154M to 23M) and 80% (GBP 15M to GBP 2.5M) respectively and the organisations directly affected include UNFPA and UKAID. The effects of the funding reduction are bound to be felt by the other stakeholders that support related work. These could be national governments or civil society organisations and anywhere in the world, but developing countries like Uganda who to a large extent source their funding for health from such multilateral entities are likely to face the brunt of the decision. In Uganda external funding to the health sector as a component of the entire health budget averaged at 48.8% over the last 5 financial years. Thus, such shifts are likely to impact national budgets, policies and programming which will impact key development indicators.
Chart 1: Development financing to Uganda’s health sector budget over the last 5 financial years
Source: Budget performance reports 2016/17-2020/21
It has been noted that there is not much collated information on domestic financing for SRHR in key budget documentation including the budget framework papers, and annual budget performance reports however, there are sporadic mentions in the reports that estimate an average of 8 billion (USD 2 Million) over the last 5 years.
While it is the inherent responsibility of governments to provide social services to its citizens, CSOs have contributed immensely by filling the existing gap. For example organisations like Reach A hand Uganda, CEHURD, Peer to peer, the SRHR alliance, etc. have contributed through providing key SRHR information, services, technical guidance and advocating within the SRHR space in Uganda. Additionally, CSOs have played the critical role of linking communities and multilateral organisations and, or vice versa, thus, the ramifications of changing trends of financing is expected to be felt.
A Report by Lester M. Salamon, titled “Putting the Civil Society Sector on the Economic Map of the World.” estimated that CSOs employ the equivalent of 54 million full-time workers, sustain over 350 million volunteers with operating expenditures of $2.2 trillion annually. Unfortunately, similar information on the domestic landscape is not readily available.
In today’s context, the decreases in funding are largely being attributed to the challenges and effects of COVID 19, however, conversations have long been had on the shifting trends of development financing to key sectors including SRHR programming. A report titled, “Funding for sexual and reproductive health and rights in low- and middle-income countries: threats, outlook and opportunities, made the following conclusion, “the future of donor investments in SRHR beyond 2020 does not look bright – at best, key donors will slightly increase their SRHR investments, but it is as likely that funds will stagnate at current levels…”. Like in the case of the UK, this funding has been reduced and in some other extreme cases eliminated completely in favour of other sectors.
The situation therefore begs the question, how should (will) local organisations cope, outside the funding bubble that we have become accustomed to? The above question is hard to comprehend especially given the years of acclimatizing to foreign funding. If you're a pessimist like me, Dambisa Moyo’s, Dead Aid, puts very many things into perspective and calls for a more localised approach to development funding. Nonetheless, it's a conversation that we should have, and now.
Speaking with a development expert, Mr. Reagan Wamajji, who Heads the Center for Policy Analysis, a Policy Think tank in Uganda asserted that CSOs need to rethink the current model of work. He said that all CSOs must, if they intend to sustain efforts, adapt to the idea of working from within and without structures of foreign funding. Reagan, however, disclaimed that the very notion of CSOs continuing to function without foreign funding is largely hinged on respective CSO leaders' passion, willingness and vitality for the cause they purport to stand for. He also challenged interested parties to find out where the funds were being repurposed for and follow the money to understand how organisations are bound to pivot. He said that organisations tend to morph and or shift priorities to follow the money, thus leaving key social ills unattended.
Ojok Okello, the founder of Okere City, a model community development project proposed the idea of Community based organising as a viable option to ensure continuity of social work including around improved community health. Ojok intimated that NGOs have made the mistake of assuming the role of overseer of local problems, unsustainably widening geographical coverage (despite varying needs) while falling short on drawing organic ideas from the people they serve and building and nurturing trust among key beneficiaries. Ojok posited that respective communities have better chances of contributing to resolving their own issues, while NGOs can play the important role of training around key health priorities, systems strengthening and monitoring. He argued that while community organising is not the silver bullet to solving societal ills, it is a key determinant of authentic social change and guaranteed sustainability of the change. When discussing the shifting funding trends, Ojok encouraged organisations to venture into social enterprise businesses to generate funds to cover the costs of operation.
What can indegenous organisations do?
In light of the granting trends, I believe social enterprise is civil society’s best bet when it comes to tackling social issues while generating revenue to sustain the efforts around the issue. The model has 3 components i.e making money, creating a solution to an existing problem, and having a positive impact on communities. Social enterprises have been studied over years and it has been deduced that if managed properly (balancing the social cause, identifying and deploying qualified personnel and resources), they can provide a unique solution to the ever elusive question of sustainability of CSO operations. Oxfam is one of the non profit organisations that have embraced this model through commercial consultancy and training enterprise, or subsidiary trading.
Crowdfunding is another unique solution for organisations that are looking to expand their resource mobilisation portfolio without the bureaucracy of standard funding streams like grants. Through crowd funding organisations appeal to like minded individuals organizations or causes to contribute funds for a particular cause without expecting repayment. However, to be able to mobilise the appropriate funds, organisations seeking support through this option have to have sound and vigorous marketing ideas to appeal to their target funders. Here, accountability and transparency is paramount because contributors are more inclined towards a cause or organisation that upholds these principles since the contributors are not involved in the management or providing oversight of the organisation activities.
Last but by no means the least, exemplary leadership/stewardship around social issues is a unique resource mobilization strategy that has worked for several social causes. Not much literature has been developed in this regard, however observations from global social causes have contributed to this assertion. Global favourites like Malala Ziauddin Yousafzai, Greta Thunberg, Nelson Mandela to mention a few are key examples of how the work can speak for itself and therefore attract key investment in the cause. This is the easiest of all the proposed avenues of resource mobilization besides grants because all that is required is belief in a cause, zeal and proactiveness of CSOs leaders and their associates. James Kouzes and Barry Posner in their 1987 book, The Leadership Challenge point to 5 key practices of exceptional leaders i.e. Model the Way, Inspire a Shared Vision, Challenge the Process, Enabling Others to Act and Encourage the Heart. These principles can help set the trajectory of the organisation for positive change.
In all this, the role of the government is to provide an enabling environment for local CSOs to thrive through a robust legal and policy regime. It goes without saying that the space for NGOs in Uganda to operate freely is gradually shrinking irrespective of the thematic area. This coupled with the effects of the COVID 19 pandemic, the shifting trends in financing for SRHR, so something’s gotta give.
Experts have pointed to the urgent need for increased government financing to the health sector, to at least 15% of the entire national budget in line with the Abuja declaration. In the short term however, emphasis has been placed on the need for adequate funding to Primary Health Care (PHC). WHO and UNICEF have described PHC as, “a whole-of-society approach to health that aims at ensuring the highest possible level of health and well-being and their equitable distribution by focusing on people’s needs and as early as possible along the continuum from health promotion and disease prevention to treatment, rehabilitation and palliative care, and as close as feasible to people’s everyday environment."
In a closed door meeting with civil society organisations advocating for budget changes in line with needs for sexual, reproductive and maternal health it was noted that the budget to primary health care was a meagre UGX 2M, 4M and 8M at HC IIs, HCIIIs and HC IVs respectively per financial year. These funds are insufficient to effectively manage PHC at all levels.
The bottom line is that civil society must adapt to the change being noted at all levels of development financing. This calls for seeking alternative financing both domestic and foreign to sustain the already existing community efforts. Each organisation must choose what works for them, and adapt its systems to support that. Government on the other hand must look within its domestic financing and strategize to improve health systems to ensure health care for all, but also improve legal frameworks that cater for alternative fundraising mediums.