FEATURE

From Millennium Development Goals to post-2015 sustainable development: sexual and reproductive health and rights in an evolving aid environment Peter S Hill,a Dale Huntington,b Rebecca Dodd,c Michael Buttsworthd a Associate Professor Global Health Systems, School of Population Health, University of Queensland, Herston, 4006, Brisbane, Australia. Correspondence: [email protected] b Director, Asia Pacific Directory on Health Systems and Policies, World Health Organization Western Pacific Regional Office, Manila, Philippines c Technical Officer, Division of Health Systems Development, World Health Organization Western Pacific Regional Office, Manila, Philippines (at time of research) d Research Officer, School of Population Health, University of Queensland, Brisbane, Australia

Abstract: Using research from country case studies, this paper offers insights into the range of institutional and structural changes in development assistance between 2005 and 2011, and their impact on the inclusion of a sexual and reproductive health and rights agenda in national planning environments. At a global level during this period, donors supported more integrative modalities of aid – sector wide approaches, poverty reduction strategy papers, direct budgetary support – with greater use of economic frameworks in decision-making. The Millennium Development Goals brought heightened attention to maternal mortality, but at the expense of a broader sexual and reproductive health and rights agenda. Advocacy at the national planning level was not well linked to programme implementation; health officials were disadvantaged in economic arguments, and lacked financial and budgetary controls to ensure a connection between advocacy and action. With increasing competency in higher level planning processes, health officials are now refocusing the post-2015 development goals. If sexual and reproductive health and rights is to claim engagement across all its multiple elements, advocates need to link them to the key themes of sustainable development: inequalities in gender, education, growth and population, but also to urbanisation, migration, women in employment and climate change. © 2013 Reproductive Health Matters Keywords: sexual and reproductive health and rights, Millennium Development Goals, post-2015 development goals, aid effectiveness, Lao PDR, Malawi, Senegal, Tajikistan The year 2005 marked a significant point for United Nations (UN) engagement in sexual and reproductive health. The Millennium Development Goals (MDGs) had brought a focus on maternal and child health, reinforced by the World Health Report 2005: Make every mother and child count.1 The potential of health systems interventions to improve maternal and neonatal mortality had been clearly demonstrated,2,3 but there were already concerns over progress on reducing maternal mortality, particularly in sub-Saharan Africa.4 That year the Partnership for Maternal, Newborn and Child Health was formed, focusing on the synergies between maternal, newborn and child health.5 But this momentum was still limited to achieving

MDG 5a: reducing the maternal mortality ratio by three-quarters between 1990 and 2015. From the perspective of sexual and reproductive health, this represents only one portion of the full spectrum of care outlined in the International Conference on Population and Development (ICPD), e.g. family planning, maternal and newborn health, addressing the public health problem of unsafe abortion, controlling sexually transmitted infections, combating harmful practices and promoting sexual health.6 It would take a further two years before a special resolution of the UN General Assembly would mark the belated addition of MDG 5b: to achieve, by 2015, universal access to reproductive health,7 reflecting the highly politicised

Contents online: www.rhm-elsevier.com

Doi: 10.1016/S0968-8080(13)42737-4

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response to sexual and reproductive health, and the continuing resistance to promoting family planning. By 2005, it was already clear that the global commitment to a comprehensive sexual and reproductive health agenda remained tenuous: with the consensus around the MDGs, major bilateral, multilateral and philanthropic donors now focused resources on HIV/AIDS and other communicable diseases, child health and a narrowly defined maternal health. The agenda for sexual and reproductive health was being played out in an increasingly complex global aid environment at the same time. This was already recognised by participants in high level consultations of the World Health Organization (WHO) and UN Population Fund (UNFPA) over the previous year, who shared concerns over country capacity to effectively represent sexual and reproductive health in the sectoral and national planning processes emerging from what was then referred to as the “new aid environment”. Since the 1990s, trends in development had been increasingly integrative: the international agreement around poverty reduction as a primary development goal contributed to a primarily economic orientation for development, and the World Development Report 19938 reinforced this framing for health. Aid rhetoric now called for a shift from funding isolated projects to integrated programmes, or preferably, to direct budget support. At a sectoral level, development coordination gained prominence through sector-wide approaches (SWAps) in health, characterised by government-led sector reform packages and donor collaboration through pooled resources. Integrated Poverty Reduction Strategy Papers (PRSPs) were intended to achieve coordination in pro-poor policy at national level. UN country officers now found their professional training, with its strong technical and programme orientation, of limited use in advising health ministries on these new structures and approaches.9 These concerns led to a programme of exploratory research, and the introduction of country-level capacity building for advocacy in national planning processes. The findings from this research and the subsequent evaluations of capacity building programmes targeting 27 WHO and UNFPA country offices in four regions10,11 have provided the core data for the comparative analysis reported in this paper. That same year, 2005, the ideas underpinning changes in the aid environment had been expressed in the declaration of the Paris Principles for Aid Effectiveness,12 calling for greater emphasis on 114

country leadership, policy alignment and harmonisation of donor processes, and a focus on managing for results and mutual accountability. These principles crystallised a desire among donors for approaches to development assistance that emphasised a shift in control towards local in-country stakeholders, with more predictable longer term financing and better synchronisation between government policy and budgetary and administrative processes. These trends contained the potential for more comprehensive approaches to sexual and reproductive health and rights, as well as other health issues. They provided options for developing policy across all the relevant sectors, defining a financial package that included both government and external funding, and building the necessary national infrastructure of health facilities and programmes that would underpin necessary service delivery. The urgency of the drive for better coordination at the global as well as local level was a response to the rapidly escalating demands of what was becoming a global development revolution.13,14 Coordination – expressed as alignment with local policy or harmonisation of donor processes – was being written into a range of development mechanisms. The commitment to reducing poverty had been translated into the health sector goals through MDGs 4, 5 and 6, to be monitored and reported annually, and integrated into other national planning processes such as Poverty Reduction Strategy Papers (PRSPs).15,16 The country UN Development Assistance Framework (UNDAF) process followed the lead of broader aid effectiveness initiatives, seeking to align UN activities with government policy and harmonize the work of different UN agencies. Sectoral approaches to development in health now had over a decade of experience of countryled planning, with donors committing to jointly funding and implementing sectoral reforms. The substantially increased funding for health experienced prior to 2005 was to continue, with a greater diversity of stakeholders and a multiplication of global health initiatives. In terms of both resources and influence, global public – private partnerships, civil society networks and private foundations now rivalled traditional multilateral agencies involved in health development such as WHO and UNICEF.13,17 This changing aid environment has been well documented at the global level.9,13,14 Our research explored how these global changes have had an impact on sexual and reproductive health policy

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and programmes at country level, comparing the findings from the exploratory country case studies conducted in 2005 and 2011 as an evidence base.7,8,18 Drawing on these studies, this paper explores the implications of global changes in development assistance for sexual and reproductive health in this period, the impact of the MDGs on framing sexual and reproductive health, the role of WHO and UNFPA in building capacity to respond to these changes at country level, and the challenges ahead as new paradigms are being explored for shaping the post2015 development goals.

Methods The research examines the collaboration between UNFPA and the WHO Reproductive Health and Research (RHR) Department from 2005 to 2012 through a series of grants and agreements on developing the capacity of their country offices to support sexual and reproductive health within the context of aid effectiveness. The initial grant, from UNFPA to the WHO RHR Department, funded the 2005 research, which focused on sexual and reproductive health representation in SWAps to development, PRSPs, and country UNDAFs. It also involved conducting a needs assessment of country office staff competencies in national planning, strategies and budgeting processes for achieving the MDGs and the implementation of the Paris Principles. Four country case studies were undertaken in 2005 (Mongolia, Nicaragua, Senegal, Yemen). A WHO/UNFPA Technical Report7 and a peer-reviewed paper18 documented the overall findings, and another paper examined the Mongolian case study.19 The four 2005 case studies were conducted using a common methodology: comprehensive literature reviews based on peer reviewed literature, policy documentation, reports and relevant documentation assembled by local consultants; structured data retrieval from Ministry of Health information systems, UN and NGO reports, local unpublished research and programme records; and semi-structured, in-depth interviews using common questions.* Over 80 key informant *The framework for the country case studies research and analysis can be found at: https://www.researchgate.net/ publication/257931178_Framework_for_analysis_country_ case_studies?ev=prf_pub.

interviews were conducted, with staff who were engaged in reproductive health programme planning within the Ministry of Health and relevant non-government organizations, senior planners from the Ministries of Health, Finance, Social Welfare, and Planning, representatives of major bilateral donors, the World Bank and other regional Banks, local WHO and UNFPA staff, and related UN agencies. The interviews asked about social, political and economic changes over the previous ten years, the extent to which sexual and reproductive health were a political priority, and their positioning in policy rhetoric. Specific themes included maternal, newborn and child health, HIV and key health indicators; relevant health services; and gender issues relating to women’s social status, roles and education. Budgetary allocations for sexual and reproductive health, financing strategies and trends over time were studied, and health services were profiled. The research also examined the positioning of sexual and reproductive health in national and health policy and their integration into pro-poor strategies. Development partners were interviewed on their engagement in policy and the mechanisms for their coordination. A common reporting format facilitated comparative analysis. After 2005, UNFPA and the WHO RHR Department continued to collaborate on project development, and in 2009 secured three years of funding from the UN Fund for International Partnerships and the Ford Foundation to develop and deliver an original training curriculum for UNFPA and WHO Country Office staff in the new aid environment, and the representation of sexual and reproductive health in national planning processes. The content was technical in its orientation, and focused on new actors, networks and modes of aid coordination (SWAps, PRSPs), budget processes, economic analysis and the implications of the Paris Principles for sexual and reproductive health. Regional and sub-regional courses were organized bringing together staff from 52 countries in Asia, Africa and Eastern Europe. The training culminated in an exercise where UNFPA and WHO representatives developed a collaborative action plan to target priority steps for advocacy of sexual and reproductive health into their own countries’ higher level planning processes. Follow-on small grants were provided for additional skills building activities in selected 115

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countries. Evaluation of the joint training programmes reported increased knowledge and advocacy activity within UNFPA/WHO offices, and as a consequence, UNFPA extended the training to include all their country offices, while WHO integrated the contents of this package into similar training offered to their country offices and Ministries of Health. Following the 2009–2011 joint project, WHO conducted a similar project to build the capacity of civil society within the context of the new aid environment with funds from the Gates Foundation. UNFPA was associated with the implementation of this project on a regional and country level. A second round of case studies was conducted in 2011 in Lao PDR, Malawi, Senegal, and Tajikistan at the close of the joint UNFPA and WHO project. Those case studies explored the changes in the aid environment for sexual and reproductive health, and country responses to those changes. The four countries were selected from the pool of countries which had undertaken the UNFPA and WHO RHR training programme, with representation from each region involved. While this meant that direct comparisons between countries over time were not possible, with the exception of Senegal, the two sets of studies provided a cross-section of low-income countries for each time period, enabling meaningful − but not linear − comparisons to be made. The research sought to map changes in the aid environment since 2005, and the evolution of how sexual and reproductive health had been expressed in country programmes, policies and national and sectoral planning processes. In addition, it sought evidence of the usefulness of the training provided, and an analysis of the collaboration between development partners in supporting national governments in representing sexual and reproductive health in sectoral and national processes. The second round of research followed the same structure described for 2005, with the four study teams sharing a common (updated) framework for the 106 key informant interviews and their analysis. Following the conclusion of the studies, all teams met to share the findings contained in the country case study reports and key lessons learned.9 The authors of this paper were engaged in the design, implementation, analysis and final synthesis of both 2005 and 2011 research processes, presented in the findings.8,9 116

Findings The new global aid environment and country level change At the time of the 2005 case studies, there was acute awareness at both global and country level of important changes in aid architecture that were under way. The promotion of SWAps and direct budget support were seen as consolidating funding for health sectors as a whole, but interviews suggested country staff were quite uncertain about the specific implications for sexual and reproductive health budgets, and were anxious that the loss of earmarked funding might make them less competitive within the budgetary process. Interviews with staff of established agencies – WHO and UNFPA, but also NGOs with a history of engagement in sexual and reproductive health – questioned how their role and mandate might need to be adjusted to take advantage of the new development partners such as the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund), and the Gates Foundation. WHO country staff expressed uncertainty about WHO policy on SWAps, awaiting guidelines subsequently released in 2006.20 UN country offices expressed concern that the plethora of new actors, each with their own modus operandi, was complicating country development processes. In Senegal, Ministry of Health respondents noted that there were multiple donors with focal reproductive health interests – safe motherhood, family planning, adolescent sexual health, female genital mutilation, advocacy around the loss of productivity from maternal mortality – but this was failing to achieve comprehensive coverage of sexual and reproductive health. With the overlap between indicators for tracking the MDGs, PRSPs and progress on the health SWAp, they noted a narrowing of focus towards maternal health and family planning. The (then) recent focus on links between macro-economics and health21 further contributed to the economic re-framing of development, with donors now focusing on poverty reduction and justifying new initiatives in terms of cost-effectiveness or pro-poor outcomes. Senior Ministry of Health staff questioned their own preparedness for negotiating this changed environment, particularly in engaging the economic framing of higher level planning meetings. Promoted to leadership because of their technical and programmatic expertise in health, they

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found it difficult to translate their insights and knowledge for other ministries: “We just don’t have the economic vocabulary to join the debates.” (Ministry of Health official, Mongolia, 2005) Even at a more basic level, the lack of access to financial data and budget planning was continuing to frustrate some sexual and reproductive health managers in the 2011 studies. In Tajikistan, the Ministry of Finance determines the health budget; allocations to the Ministry of Health are made through the Treasury, and cover republican health centres, national health programmes and capital investment. Health care facilities at regional, municipal and district levels are funded through district hospitals, which effectively act as local health departments. Dispersals at district level and local taxes fund rural health facilities − but funds for sexual and reproductive health are not able to be separately identified within this complex financing matrix. Although the National Reproductive Health Plan 2005–2014 has been developed, it has not been costed, and sexual and reproductive health advocates within the Ministry of Health are looking to the development of a SWAp to create external pressures that may give them an understanding of their financial situation: “We do not know how to measure our funding. If we knew how to do it, we would have better allocation of the budget and better coordination of the development partners.” (Ministry of Health official, Tajikistan, 2011) By the time of the 2011 case studies, the new aid environment was arguably no longer new, yet there was a widespread perception on the part of government and donor respondents that there had been a compounding of the complexity already documented in 2005.14,22 Despite this, each of the research teams for the 2011 case studies independently reported the relative confidence that country offices, Ministries of Health and civil society organizations now demonstrated in framing development interactions in terms of the principles of the aid effectiveness agenda. In 2011, the Paris Principles were much better recognized and institutionalized at country level, and were a well entrenched feature of policy dialogue both in the health sector and more broadly. For example, the Lao People’s Democratic Republic had made a commitment to

the principles of aid effectiveness, with governmental and 22 other partners in the “Vientiane Declaration on Aid Effectiveness”.23,24 Senior health planners raised concerns around the rate of progress in aid effectiveness documented for the Accra Agenda for Action25 and interest in the preparations for the 4th High Level Forum on Aid Effectiveness at Busan. Although concerns about the changing aid environment remained, these had evolved from a relatively abstract focus on roles and mandate, to a more practical interest in how to make the aid effectiveness agenda operational in a complex local environment. Ministry of Planning interviewees in the Lao PDR saw advantages in moving beyond a single sectoral focus: more effective collaboration was possible if planners were to look beyond the health MDGs alone and engage some of the key donors and the development banks in broader alliances that would include health within more comprehensive development strategies, including education and infrastructure: “For health, you know, there are also issues in MDG 8 – developing the partnership for development – but locally.” (Ministry of Planning official, Lao PDR, 2011) The other common theme evident in the 2011 study was the recognition by Ministry of Health and WHO staff of the strategic importance that the aid effectiveness agenda might bring to advocacy for health systems strengthening and through it, the provision of emergency obstetric and newborn care. Respondents saw this shift towards health systems strengthening as partly a reaction to the very high levels of development assistance earmarked for communicable diseases in the early 2000s, but also the result of a natural synergy between the agendas of sector-wide reform, strengthened health sector planning and budgeting processes, and more harmonized and aligned aid. Global public health initiatives such as the Global Alliance for Vaccines and Immunisation (GAVI Alliance) and the Global Fund had responded rapidly to changes in aid architecture by seeking to become more “systems friendly”,26,27 each signing compacts with the International Health Partnership Plus (IHP+),28 actively engaging in the development of health systems tools,29,30 and increasingly reflecting on their contributions to human resources for health.31 All the Ministries of Health in the 2011 case study reported receiving specific health systems strengthening grants from the 117

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GAVI Alliance and/or Global Fund, releasing significant revenues for national health budgets.26,32 Coordinating coordination in the new aid environment With the growing participation of agencies such as the GAVI Alliance and Global Fund, and their attempts to extend their engagement beyond their narrowly defined mandates, Ministry of Health staff and their WHO and UNFPA country office advisors were now grappling with a growth in mechanisms to coordinate this increasingly diverse field of development stakeholders and programmes. By 2011, all countries studied had faced requirements for new coordination structures: the PRSPs and reporting of MDG progress brought national stakeholders together; the GAVI Alliance made a health sector coordination committee a prerequisite for health systems strengthening funding; and the Global Fund had set up its own Country Coordinating Mechanism (CCM), often with overlapping, but not identical, membership. The Health Systems Funding Platform, created in 2009 as a collaboration between the GAVI Alliance, Global Fund and World Bank, was beginning to coordinate existing health systems strengthening activities in their existing programmes by 2011, and exploring further collaboration based on common application forms and the Joint Assessment of National Strategies (JANS).33 The JANS had been developed by the IHP+ as an independent assessment of countries’ health sector planning processes and fiduciary systems, allowing donors to identify potential collaborations in sectoral budget support.28,34 Senegal had commenced the JANS process as part of its progress towards an IHP+ compact, adding this to its existing coordination mechanisms: the health SWAp, Country Coordinating Mechanism, National Health Development Plan, Mid-Term Expenditure Framework and the National Plan for Development Assistance. In 2005, the study had found that the two dominant instruments of aid coordination were SWAps (at sector level) and PRSPs (at national level). Like SWAps, PRSPs have also evolved and diversified. Indeed, the PRSP as an instrument linked to debt relief no longer exists.16 Rather, poverty reduction strategies (now written in lower case) commonly are branded under a variety of names driven by local context and national plans, examples being the Economic and Social Policy Document 2011–2015 in Senegal, 35 Malawi’s Growth and 118

Development Strategy 2006–2011, 36 and the 2004 Lao PDR National Growth and Poverty Eradication Strategy.37 By 2011, government and development partner respondents recognised the apparent inevitability of the increasing range of coordination structures, and the growing numbers of forums at national, sectoral and even sub-sectoral levels. Yet they also noted that efforts to enhance alignment and harmonization of development partners – which carry high transaction costs for both governments and partners – have been slow to translate into improved policy support or operational efficiencies. The Government of Malawi’s recognition of the SWAp secretariat as their Health Sector Working Group secretariat streamlined national coordination mechanisms and has consolidated policy direction, but operational capacity continues to lag behind the development of sector governance. The (then) recent failure in Malawi to secure Round 10 Global Fund funding was attributed to poor absorptive and dispersal capacity of funding at local level, and weak accountability mechanisms from the previous rounds. Earlier confidence in the Senegal health SWAp had eroded, with donors looking to the proposed IHP+ compact as an alternative locus for coordinating development assistance and securing additional financial support. In the interim, development partners in the country have not demonstrated a commitment to government policy directions, as high rates of turnover among Ministers and senior administration officials have disrupted policy direction and hampered programme operations. The 2012 electoral crisis has undoubtedly further reduced government capacity. Reviews of progress in the country point to greater need for predictable development assistance and better synchronization with national planning and budgetary frameworks. Although a Health Sector Working Group provides coordination of donor activities and is moving towards creating a SWAp-like process for organizing development assistance, the persistence of having to administer multiple projects through independent implementation units (and maintaining different human resources policies and salary scales) continues to undermine attempts at harmonization at the level of implementation. Ironically, increased donor support for health has made it difficult for Ministries of Health to successfully argue for additional domestic sources

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of revenue for the sector in the countries where the case studies were conducted. To varying degrees, this was the experience of all the governments studied. In Malawi, development assistance to the health sector increased while government budget allocations to health were reduced and redirected to other line ministries. The Ministry of Finance interviewee from the Lao PDR spoke frankly of the dilemmas it faces around the predictability and sustainability of aid, the perceived advantages health has in securing development assistance, and the disquiet within the public service caused by unilateral decisions of donors, such as supplementing salaries of health personnel linked to their projects – inequitable in the eyes of other public servants. Sexual and reproductive health in the new global aid environment With the MDGs adopted as the basic metric for most approaches to development and poverty reduction, the key MDG targets in all countries studied enjoyed high government recognition in both national and sectoral planning processes. The underlying concepts were readily accessible: decision-makers in Finance, Planning and Social Welfare understood the importance of preventing maternal and neonatal deaths, reducing death and disability in children, and reducing the burden of AIDS, tuberculosis and malaria. Consequently, maternal, newborn and child health was reported as strongly positioned in sectoral, national and global health agendas, and central to broader development discourse. The 2005 country studies, however, had identified a lack of connection between advocacy for reduction of maternal mortality in national-level planning and the necessary linkage to effective programmatic responses through resource allocation, capacity-building and human resources development. The 2011 case studies suggest that this problem persists: despite a closing of the gap between policy and programmes, the limited progress with improving health outcomes has shown the importance of strengthening health systems – particularly for maternal and newborn health. Furthermore, the renewed interest in maternal and newborn health has not unequivocally improved the profile of sexual and reproductive health; if anything, it has reinforced historical distortions of the broader sexual and reproductive health agenda, marginalizing attention to family

planning, and often neglecting the rights agenda and prevention of unsafe abortion.38 In the Lao PDR, the prioritisation of MDGs 4 and 5 has led to the harmonization of key donor funding around the implementation of the Integrated Package for MNCH services, launched in September 2009, with WHO and UNFPA collaborating with the World Bank and Asian Development Bank on producing a single plan and financial report across all agencies. From three separate programmes, training for midwives has been standardized, common allowances agreed, antenatal care promoted, clinics equipped, vouchers for delivery offered, and where necessary, accommodation for pregnant women close to facilities provided. This now shares many of the attributes of a programme-based approach, with the World Bank collaborating on skilled birth attendance and community-based distribution of contraceptives with UNFPA; and on voucher schemes for free deliveries with WHO. But interviewees at the development banks felt that the UN approach to programming and operationalizing support to the government was very vertical, and confined by agency mandate. Budgetary and structural issues feed into this: with donors maintaining funding as project support rather than direct budgetary support, the limited Lao PDR budget remains largely committed to recurrent costs (principally salaries) leaving development partners largely responsible for protecting sexual and reproductive health (and other priority programmes) from slippage due to budget shortfalls or shifting domestic priorities. Yet, with neither WHO nor UNFPA active in discussions around the national poverty reduction strategy, sexual and reproductive health issues have a relatively low profile at national level. Finally, each of the country studies found that the increased diversity in the health sector landscape in terms of actors, alliances and processes had impacted on the profile of sexual and reproductive health in sectoral and national planning processes. While the diversity is shared, each of the 2011 case studies report on differing expressions of this impact, reflecting the varying development histories and structures of each country. The Senegal experience is instructive: in 2005 the health sector SWAp provided a promising locus for donor coordination, and sexual and reproductive health had been a stated priority in every development plan up to that date. Yet in 2011, sexual and reproductive health as an integrated 119

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concept no longer appeared in either the Economic and Social Policy Document 2011–2015 (Senegal’s third poverty reduction strategy paper)35 or the National Plan for Health Development 2009–2018.39 Indeed, health issues in general appear to have lost their prominence in the current National Policy for External Assistance in Senegal.40 Multilateral agency respondents interviewed were unclear whether this was a sign of a broader shift towards favouring “productivesector” investments or of weakened leadership in the health sector. In either case, having been formerly featured in national planning, the absence of health in general, and sexual and reproductive health in particular in current national plans, draws attention to the uncertain staying power of these issues in national political arenas. In Malawi and the Lao PDR, sectoral governance structures ensure that sexual and reproductive health are well integrated into the planning process for health and poverty reduction. Strong technical support from WHO and UNFPA and significant donor funding have contributed to this positioning, but have brought with it the risks attendant with donor dependency – unpredictable financing, vulnerability around procurement of supplies, competition with changing donor priorities, and withdrawal of state financing.

Discussion In 2011, while the second round of case studies were being conducted, the new aid environment took another turn: the 4th High Level Forum on Aid Effectiveness in Busan, Korea, redefined “aid effectiveness” to mean “development effectiveness”.41 Confronted by the multiple determinants of health, the escalating need for resources and a proliferating network of stakeholders, the organisers of the Forum were aware of the need to reframe development assistance, recognizing broader partnerships between nations and donors, new development partners such as Brazil and China, South-South collaborations, and the importance of trade rather than aid, in future development frameworks. Seeing an uncertain future in terms of harnessing these newly recognised stakeholders, they nevertheless underlined the importance of achieving the MDGs – in particular MDG 5 – in even the most fragile states, seeking a new consensus for action and the stripping away of policies that currently frustrate the achievement of results.42,43 120

Nevertheless, the assessment of progress within the evolving aid environment has been ambiguous: the interim assessment of progress for the 2008 Accra Action Agenda suggested a deepening of the rhetorical commitment to the Paris Principles, but “highly uneven” implementation.44 Evaluation of the aid effectiveness targets demonstrated achievement in only two of the 12: strengthened capacity by co-ordinated support and the level of untied aid.49 Predictability of aid increased by only 1% from 42%, disappointingly short of its target of 71%.45 The Global Financial Crisis has seen pledges unrealized,46 and the Global Fund Round 11 deferred. The Busan Partnership for Effective Development Co-operation has proposed a Global Partnership for Effective Development Co-operation, but its specific roles and relationships are still being developed. 41 Given a development landscape infinitely more complex than that envisaged in the Paris principles, the uncertainty around how to shape new partnerships to accommodate this development diversity is not surprising. With the 2015 MDG deadline, the global focus on the MDGs, and on MDG 5 in particular, presents opportunities for accelerated action on maternal health, but may at the same time delay advancing comprehensive sexual and reproductive health. For our research teams, as they have synthesised the lessons from the countries studied, the emphasis on maternal mortality of the past decade has been seen as welcome. The consequent distortions of the sexual and reproductive health agenda seem to be an almost inevitable by-product of MDG-focused investment, but raise an expectation or at least a hope that this may change in the post-2015 agenda. At the global level, the first rounds of exploration of the proposed post-2015 development goals seem to support such a change: the report of the High Level Panel of Eminent Persons on the Post-2015 Development Goals extends the MDG 5a maternal mortality goal, but adds a separate target, ensuring universal sexual and reproductive health and rights.47 Yet, this focus on rights will likely form one of the potential fault lines as the post-2015 development goals are debated and amended. The 2005 and 2011 country case studies revealed that within national planning processes and programme operations, rights did not figure prominently at all within government discourses on sexual and reproductive health, and in some

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settings rights were not an element in civil society advocacy either. Even with the specific focus on the political positioning of sexual and reproductive health in national and sectoral policy, rights did not emerge as one of the influencing factors on policy development. Evaluation of the WHO and UNFPA country office staff participants in training has confirmed a significant increase in awareness of global development politics and technical knowledge relevant to the evolving aid environment. But we argue that while the rhetorical focus on maternal health has increased the rights-based profile in the consciousness of national stakeholders, this has not spilled over into other elements of sexual and reproductive health and rights, such as the right to control fertility, have a safe, legal abortion or control sexually transmitted infections.

Conclusions As anticipated in our analysis and synthesis of this research, the post-2015 development goals debate has reopened the global policy arena to inclusion of sexual and reproductive health and rights. Securing an overt target “Ensure universal sexual and reproductive health and rights” in the initial illustrative goals – with specific reference in the text to maternal mortality, contraception, safe abortion, sexually transmitted diseases and the needs of adolescents – provides a platform from which to lobby for a broadening of the MDG agenda. The next phase of the process, which develops the goals in terms of sustainable development, provides a unique opportunity for sexual and reproductive health and rights to locate itself centrally in terms of social sustainability. But as Shiffman points out, the ultimate priority of a global policy agenda depends on a complex of issues: the actors involved, the effectiveness of their communication, the current political context itself and the characteristics of the issue.48 For sexual and reproductive health and rights, this will depend on member states developing concrete policy and programme positions, and the political will to advocate for these locally, nationally and into the global debate. The alliances for sexual and reproductive health and rights will at times be advantaged by other geo-political interests as the post-2015 debate refocuses on sustainable development, but face risks in negotiated “trade-offs” in exchange for support on more contentious

environmental outcomes. Political leadership is imperative in driving this process. The systematic building of political will for safe motherhood has been documented;49 that same process needs to be extended to sexual and reproductive health and rights. In terms of immediate action, the research shows that there is a tactical window through which to raise the profile of sexual and reproductive health and rights priorities, and integrate them into multiple policy windows: universal health coverage, health systems strengthening, adolescent health − as part of health at every life stage, as well as within gender equality, and in the increasing recognition of the centrality of gender and sexuality issues to HIV. The frames of development assistance are again changing: our assessment is that new thematic and programmatic frameworks will be as least as influential as the generic frameworks focusing on aid effectiveness that were dominant at the commencement of this research. Certainly, the re-casting of aid effectiveness as development effectiveness is likely to further lessen the focus on aid instruments and modalities such as pooling of funds − a transition that our case studies suggest is already under way in some countries. With the Open Working Group’s emphasis on Sustainable Development Goals now leading the post-2015 debate, sexual and reproductive health and rights advocates need to reframe their arguments in terms of the themes that have been articulated beyond health: sustainability, inequalities − in particular in relation to gender, education, growth and population.50 The sustainable development agenda opens the possibilities of linkage to issues where sexual and reproductive health and rights are integral, but where we have not previously connected: urbanisation, migration, jobs, climate change. This research suggests that the political and economic language of the new aid environment has been mastered, but without the necessary rights that would ensure its integrity. In the reframing of development assistance, sexual and reproductive health and rights advocates − within civil society, member states and the global community − need to assert the priority of rights within this next global transition. There is a need for vigilance and advocacy to ensure that the emerging focus on sexual and reproductive health and rights in the post-2015 development goals process remains comprehensive and framed in a rights-based 121

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approach, but also deeply embedded in the broader sustainable development agenda. Fragmentation of the health agenda and of the aid effectiveness agenda can too easily lead to a frag-

mentation of the sexual and reproductive health and rights agenda − something to guard against in the context of the continuing dynamic complexity of development assistance.51

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Résumé Utilisant les études de cas de pays, cet article donne un aperçu de l’éventail des changements institutionnels et structurels de l’aide au développement entre 2005 et 2011, et leur impact sur l’inclusion d’un ordre du jour de la santé et des droits sexuels et génésiques dans les contextes nationaux de planification. Au niveau mondial, pendant cette période, les donateurs ont soutenu des modalités plus intégratrices de l’aide – approches sectorielles, cadres stratégiques de lutte contre la pauvreté, soutien budgétaire direct – avec un recours accru aux cadres économiques dans la prise de décision. Les objectifs du Millénaire pour le développement ont attiré davantage l’attention sur la mortalité maternelle, mais aux dépens d’un agenda plus large de santé et de droits sexuels et génésiques. Le plaidoyer à l’échelon national de la planification n’a pas été suffisamment lié à l’application des programmes ; les responsables de la santé étaient désavantagés dans les argumentations économiques et manquaient de contrôles financiers et budgétaires pour garantir une connexion entre le plaidoyer et l’action. Avec des compétences accrues dans les processus de planification aux niveaux supérieurs, les responsables de la santé se recentrent maintenant sur les objectifs du développement après 2015. Pour que la santé et les droits sexuels et génésiques obtiennent un engagement sur tous leurs multiples éléments, les activistes doivent les lier aux thèmes clés du développement durable : inégalités sexuelles, éducation, croissance et population, mais aussi urbanisation, migration, femmes et emploi, et changement climatique.

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Resumen Utilizando investigaciones de estudios de casos de país, este artículo ofrece información sobre una variedad de cambios institucionales y estructurales en asistencia para el desarrollo entre 2005 y 2011, y su impacto en incluir una agenda de salud y derechos sexuales y reproductivos en ámbitos de planificación nacional. A nivel mundial durante este plazo, los donantes apoyaron modalidades más integrales de ayuda – enfoques sectoriales, artículos sobre estrategias de reducción de pobreza, apoyo presupuestario directo – con mayor uso de marcos económicos en la toma de decisiones. Los Objetivos de Desarrollo del Milenio incrementaron la atención a la mortalidad materna, pero a expensas de una agenda más amplia de salud y derechos sexuales y reproductivos. Las actividades de promoción y defensa a nivel de planificación nacional no estaban bien vinculadas con la ejecución de programas; los funcionarios de salud estaban en desventaja en argumentos económicos y carecían de controles financieros y presupuestarios para asegurar una conexión entre la promoción y defensa y la acción. Con creciente competencia en procesos de planificación de nivel superior, los funcionarios de salud ahora están reenfocando los objetivos de desarrollo post-2015. Si el campo de salud y derechos sexuales y reproductivos ha de asegurar participación en todos sus múltiples elementos, los promotores deben vincularlos con las temáticas clave de desarrollo sostenible: desigualdades en género, educación, crecimiento y población, pero también con urbanización, migración, empleo de mujeres y cambios climáticos.