Adding It Up 2024: What the Latest Data Mean for Policy, Funding and Advocacy

Transcript:

Speaker 1: Thank you all so very much. Thank you all so very much for being here. My name is Onikepe Owolabi, and I'm Vice President for International Research at the Guttmacher Institute. It's my utmost pleasure to welcome you to today's webinar, Adding It Up: What the Latest Data Mean for Policy, Funding and Advocacy. Thank you so much for being here, because this convening is holding at a critical moment in time. Across the globe, the landscape for sexual and reproductive health and rights is rapidly shifting, and in many cases, funding is becoming more constrained, anti-rights movements are gaining ground and trying to push back against the argument for bodily autonomy, and to erode hard-won gains in health outcomes, social and economic empowerment, and gender equality. There is a critical need to make a strong, evidence-based case for investment. And even though the current times seem extremely challenging, one of the most important tools in our arsenal is that we do know what works. The evidence is clear. Investing in family planning is not only a health intervention, it is a powerful driver of social and economic development. When people can decide if and when to have children, the ripple effects are profound, from improved health, education, and employment outcomes to stronger, more resilient families, communities and economies. Yet too often, decision-makers lack the data they need to fully understand and advocate for these returns, especially in our current, challenging funding environment. And that's why we're excited to be sharing with you evidence from Adding It Up and the Family Planning Impact Consortium today. These resources quantify both the costs of delivering comprehensive sexual and reproductive health services and the wide-ranging benefits of those investments. They equip all of us with the evidence we need to inform policy, to strengthen our advocacy, and to guide funding decisions. Today's session is designed not only to share the latest data, but to demonstrate how it can be used in practice across policy, advocacy, and funding contexts. Throughout this presentation, we welcome you to submit questions using the Q&A feature at the bottom of your screen. We will have time at the end of the session to address as many of your questions as we can. Now, I'm going to introduce you to my colleagues, who will walk us through the latest global findings and trends. Today, my colleague, Dr. Elizabeth Sully, our Director of International Research, and Dr. Chelsea Polis, a Principal Research Scientist who leads our Adding It Up project in collaboration with Beth, will be presenting to you. I'm passing it over to you, Beth and Chelsea.

Speaker 2: Thank you, Oni. I'm happy to be sharing with you all today some of our new research that shows the transformative impact of investing in family planning. If you can go to the next slide. So the first project we're gonna talk about today is Adding It Up, which really, for over two decades now, has shown that sexual and reproductive health is a best buy for both global health and for development. We're also gonna be sharing new results from the Family Planning Impact Consortium that builds on Adding It Up. And together, this evidence shows that investing in family planning is about thriving, not just surviving. Family planning catalyzes tremendous benefits for women, for their families, and for their communities. It not only improves women's health and saves lives, it also saves health systems' costs. It increases women's access to economic and educational opportunities, and it increases women's economic empowerment. Now, let us not just tell you that, but show you the data that explains it and the tools that are available that put this data into your hands. Next slide. We're excited to share with you today the latest data from Adding It Up 2024 that we released late last year at the International Conference on Family Planning. Adding It Up 2024 shows the need, the impact, and cost of providing sexual and reproductive health services in all low and middle income countries. Showing the investments needed and the return on those investments has never been more critical. Funding is shrinking, and yet the unmet need for care persists, creating a widening gap between the available resources and the investment required to meet women's needs. In this increasingly constrained funding environment, evidence that accurately reflects women's sexual and reproductive health needs and quantifies the true scale of the financing gap is critical, both for making the case for sustained financing and increased investments in both contraceptive care as well as broader sexual and reproductive health services. Next slide. In Adding It Up, we assessed the number of women of reproductive age who need and receive contraceptive services; pregnancy-related care, including maternal health care and abortion services; newborn care; and treatment for the four main curable STIs. Together, these are services that ensure that people can decide whether and when to have children, to experience safe and satisfying sexual lives, and to have safe pregnancies and deliveries, and to have healthy newborns. We produce estimates for all 128 low and middle income countries as of 2024, as well as specific estimates for adolescents aged 15 to 19. Next. Adding It Up produces data on need, cost, and impacts. This includes, what is the need and coverage for sexual and reproductive health services? What is it costing us currently to provide that care? And what is it gonna cost us to scale up to meet all the need? And finally, when we make these investments, what is the impact and the return on investment?Both in terms of the health benefits as well as the cost-savings. So with that, let me dive into the latest data from Adding it Up 2024. Next. I wanna start by talking about contraceptive need. As of 2024, there were 714 million women in low and middle income countries who were using modern contraceptive care. That means in this climate of decreasing funding, we need to ensure that 714 million women can continue to access these services, even in the face of serious financial as well as ideological threats. In addition to these 714 million women, there are 75 million women in low and middle income countries who are using traditional methods of contraception. But there are millions of other women who want to avoid pregnancy and aren't currently using contraceptive methods. Next. A major update in Adding It Up 2024 is how we are defining unmet need for contraception. This new approach considers not only whether a woman is currently using modern contraception, but also whether she expresses an interest in using it in the future. This shift creates a more person-centered way of measuring contraceptive need. Our latest 2024 data provides three different ways to measure unmet need, from the narrowest to the broadest possible definition. Our field for a long time has relied on the broadest definition of need, unmet need for modern contraception, which is defined as women wanting to avoid pregnancy who are not using modern contraception. The underlying assumption is that people who want to avoid pregnancy want to both use contraception and specifically want to use a modern method. Some women may be using traditional methods of contraception and may not necessarily want to switch to modern methods. When we no longer assume that traditional method users have a contraceptive need that's unmet, then we're looking at the measure of unmet need for any contraceptive method. This is the group in the middle, the, the sort of in-between definition. And the narrowest definition that we're using in Adding It Up 2024 is called unmet demand, and it focused specifically on women who want to avoid pregnancy, and critically, who say they are interested in or are open to using contraception in the future. This makes our estimates more grounded in women's own preferences. Next. In Adding It Up 2024, we focus on the costs and impacts of meeting the need for those with an unmet demand. By focusing in on this group, we're moving towards a more person-centered measure of contraceptive need, where women's own desires and preferences are being used to guide our measurement of need. But also, in this really difficult climate for financing contraceptive services, it is strategic to focus first on those with the most pressing need. And so we are saying that this measure is not only a more person-centered measure, but a strategic one for us to be focusing on in this current climate. Next. Let me show you what these estimates look like for 2024. So for 2020, as of 2024, it's estimated that there were 214 million women in low and middle income countries that have an unmet need for modern methods. These are women wanting to avoid pregnancy who are either not using a method or who are using a traditional method. Next. When we move to unmet need for any method, where we no longer assume that traditional method users necessarily have an unmet need, we find that there are 139 million women in low- and middle- income countries who have an unmet need for any contraceptive method. Next. And when we focus further among, among those 139 million women, how many say that they want to use family planning at any point in the future? We see that as of 2024, we estimate that 78 million women in low and middle income countries had an unmet demand for contraception. Next. If we look at unmet demand by age group, we find it is higher among adolescents when compared to all women of reproductive age. Among women wanting to avoid pregnancy in low and middle income countries, unmet demand is 25% among adolescents versus 8% for all women. And this inequity between adolescents and all women of reproductive age is larger when we look at this new indicator. So unmet demand also helps us see some of these inequities between adolescents and all women are also greater than we were previously estimating. I'm going to turn it now to my colleague, Dr. Chelsea Polles, who's going to talk us through our cost and impact estimates from Adding It Up 2024. Over to you, Chelsea.

Speaker 3: Great. Thanks, Beth. And hello, everybody. Thanks for being here today. So let's first look at what it would cost simply to maintain contraceptive care at 2024 use levels. This costs about 9.2 billion US dollars across all low and middle income countries, and this includes 1.5 billion on commodities, drugs, and supplies, 3.1 billion for health worker salaries, and 4.6 billion in other indirect programs and systems costs. A lot of really excellent and important work is happening around the commodity financing gap, and this is critical given the dismantling of US foreign aid for family planning and other cuts to official development assistance. And it's important to be aware that commodities are one piece of what's needed to maintain contraceptive services and access. Next slide. Now, what would be the costs of meeting all contraceptive need, meaning supporting current users plus supporting those 78 million with unmet demand that Beth mentioned? Contraceptive care costs would increase from 9.2 billion to 14 billion annually, and while an additional 4.8 billion is obviously a lot of money, Adding It Up shows that this continues to be a cost savings investment, which I'll turn to shortly. Next slide, please. So now let's move beyond a focus on just contraception and talk about investing in comprehensive sexual and reproductive health and rights more broadly. Among all 206 million pregnancies in low- and middle- income countries in 2024, a little over half, or 119 million, resulted in a live birth. Some 30 million resulted in miscarriages and stillbirths, 34 million in unsafe abortions, and 24 million in safe abortions. And additionally, about 247,000 women die from causes related to pregnancy and childbirth. Next slide. Women in low and middle-income countries have a range of sexual and reproductive health needs that are not being fully met due to insufficient access to maternal and newborn health care. For example, 37% of women made fewer than four antenatal care visits during pregnancy. 22% did not give birth in a health facility. Further, 47% of women and 23% of newborns experienced complications during delivery and childbirth and did not receive the necessary care. Next slide. This slide shows costs to meet needs for contraceptive, pregnancy-related, and newborn care, and sexually transmitted infection care across 128 low and middle income countries. In 2024, the amount spent on sexual and reproductive health services was $7.51 per capita in low and middle income countries. To meet all needs for essential sexual and reproductive health services, an additional $8.05 per capita would be needed, representing a total cost per capita of $15.56. From an annual total cost perspective, the amount spent on these sexual and reproductive health services was about 50 billion in 2024, and an additional 54 billion would be needed to meet all needs, bringing total costs to 104 billion. The largest share of these costs is for maternal and newborn care, at nearly 80%. Next slide, please. So how does that additional 54 billion needed break down geographically? The additional investment needed is largest in Africa, at 40 billion. This is where unmet needs are highest and where health systems require the most strengthening. Within Africa, the largest additional investments are needed in Western Africa, at about 12 billion, and the lowest in Southern Africa, at 2.5 billion. The Asia region would require the next highest level of investment at about 12 billion, and within Asia, the largest additional investments are needed in Southern Asia at nearly eight billion, versus other subregions of Asia, which are all below two billion. The amount of additional annual investment needed is lowest in Latin America and the Caribbean, at slightly over one billion, with the largest amount needed in South America. Next slide, please. The evidence is clear that there are immense health benefits that can be achieved from meeting all needs. If we met the unmet demand for contraception and ensured all pregnant women and newborns receive recommended care, unintended pregnancies and unsafe abortions would drop by one-third and maternal and newborn deaths would drop by two-thirds. The impacts of addressing these needs would obviously be transformative. Next slide, please. We can also look at return on investment in terms of cost savings to the health system. Every additional dollar investment in contraceptive care saves nearly two and a half dollars on pregnancy-related and newborn care. Through investing in women's ability to decide if and when to have children, unintended pregnancies are reduced, and with fewer unintended pregnancies, fewer costs are incurred by health systems for abortion care, maternal care, and newborn care.So investing in sexual and reproductive health and rights not only saves lives, it reduces costs. Next slide, please. I'd like to leave you with three main takeaways from the latest Adding It Up 2024 release. First, it's more important than ever for governments to know where to focus their resources. And the 78 million women with an unmet demand for contraceptive care gives us a strategic starting point. It's also important that we use measures of need that are grounded in women's own expressed desires and preferences, as Beth talked about. It would cost just $15.56 per person per year to meet the need for these essential sexual and reproductive health services in all low and middle income countries. And finally, this is an investment worth making because the returns are transformative. By making this investment, we save lives, improve health, and end up reducing costs. I'll now turn things back over to Beth to talk about the other benefits of investing in sexual and reproductive health.

Speaker 2: Thank you, Chelsea. All right. So thank you, Chelsea, for, for talking about the impacts and costs and the data that we generate on really the the value of investing in family planning on health outcomes. But another key argument that we have traditionally made as a field in favor of, of investing in family planning has been that it catalyzes tremendous longer-term benefits for women, their families, and their communities, particularly related to economic and social empowerment. Many of these outcomes though have really been difficult to quantify in low and middle income countries. Next. So in 2022, Guttmacher convened the Family Planning, or FP Impact, Consortium as a collaborative endeavor to apply innovative modeling approaches to available secondary data, with the aim of generating new policy-relevant scientific evidence on the economic effects of family planning for women in Sub-Saharan Africa. Next. The work that I'm gonna be presenting from the FP Impact Consortium is work that was conducted in 11 countries in Sub-Saharan Africa, which you can see in blue on the map. We had four research teams based in the United States, Europe, and Africa. Three consortia used already available data, such as PMA data or the demographic and health surveys, or the measurement learning and evaluation program data to test out innovative methods of causal, causal inference to examine the effect of family planning on women's economic empowerment. One modeling group had access to longitudinal data from an ongoing randomized control trial that focused on adolescents and young people in Cameroon, Ethiopia, and Tanzania. While each team took a different approach, there were many collaborative efforts to choose similar indicators for this effort. And this was really selected in collaboration with a multinational, multidisciplinary expert advisory group that was supporting the overall consortia. Next. So across the, the, models, family planning was largely defined by measures of contraceptive use, with some groups looking at current contraceptive use or contraceptive use duration, or even the adoption of a contraceptive method among people who have never used contraception before. One team also looked at knowledge and access to contraception, which are particularly important factors for adolescents and young women. The outcomes that were examined across the model were women's participation in paid work, financial decision-making and control over household resources, and other decision-making and measures of autonomy. Our goal was to robustly document the causal impact of family planning on women's economic empowerment and to work collectively with different data, countries, and analytic approaches to quantify this. I'm gonna give you some of the headline results today. But if you wanna dive in deeper, each of the team's papers are under review at academic journals, and there'll be a summary paper really bringing all of this evidence together when the, the individual papers are published. But what we wanted to do today is really give an early view into what we found across all of these studies. countries. Next. Our overall findings are clear. Family planning expands women's economic opportunities. But the results are complex. Not every outcome was significant in each context, and I'll talk about some of that nuance in a moment. But what is clear is that across modeling approaches, outcomes, and country context, there is a clear pattern showing that family planning has a positive economic impact on women. Let me talk through some of the examples of that. So in Senegal and in Kano, Nigeria, we found that women with access to family planning were one and a half times more likely to join the workforce within a year. In Burkina Faso, Niger, and Kenya, the longer women used family planning, the more economic power they gained, showing more years of paid employment and greater control over their earnings. In Kano, Nigeria, the DRC, and Kenya, women experienced greater financial autonomy, with as much as a 15% increase in control over their earnings. And in, in Kenya and in Kano and Burkina Faso, women were 18% more likely to have savings one year later. What we see is a clear pattern of family planning expanding the economic opportunities and furthering women's economic empowerment. Next. These findings are promising, but they come with important nuances. The impacts of family planning programs both depend on and are shaped by many factors: geography, access to health care and education, labor market structure, and societal attitudes towards family size and gender roles. Across the three modeling teams, we saw some of this important nuance. Urban women and non-agricultural workers show the strongest effects, while impacts in rural settings were more modest. And empowerment looks different across populations. For a 16-year-old, it might mean staying in school and delaying marriage, while for a 30-year-old, it could be about workforce participation and control over earnings. The early trial data from Ethiopia, Tanzania, and Cameroon showed positive but not yet statistically significant associations, particularly for younger women, where economic impacts might take longer to materialize. Future data is really gonna give us an insight into how access shapes these life trajectories. We can share with you in the chat a tool produced by the for the consortium by Avenir Health that allows to use the work of the consortium in your decision-making processes. It's called the FP Impact Tool, and it shows both the underlying conceptual model behind this work and then has a dynamic model that brings together data from the literature as well as our findings and really lets you visualize how strengthening or conversely backtracking on investments in high-quality voluntary contraceptive services may impact women's fertility as well as their economic outcomes. Next. Contraception demonstratively advances girls' and women's empowerment in the near term. But the full transformative potential for women themselves and for the next generation will unfold over decades, not the years of our studies. That generational timeline has important implications for how we measure s-success and how we ensure that we sustain investment. The evidence is clear. Sexual and reproductive health is more than an effective health intervention. It advances gender equality. It builds stronger and more productive economies. And Adding It Up, together with FP Impact, shows the investment that's gonna be required for countries to realize that vision. The research we share today from FP Impact also shows why that investment is gonna pay dividends across generations. Next. I'm gonna hand things over to my colleague Jessica Rosenberg, who's a research associate at The Guttmacher Institute and one of our core staff leading the Adding It Up 2024 analysis. Jess has prepared a video demo to walk you through the tools that we have developed. These tools are designed to make sure the data doesn't just live in reports, but it actually gets into the hands of advocates and donors and policymakers who can use that data to drive change. So we'll play her video for you now, and I'd suggest you have your phones ready 'cause we have some QR codes on the slides as she's going through the tools so you can start to pull them up and look at them yourselves.

Speaker 4: Welcome. My name is Jessica Rosenberg, and I work as a research associate on Guttmacher's Adding It Up team. Today, I'm going to walk you through Guttmacher's Adding It Up tools, a suite of resources designed to help researchers, advocates, and policymakers understand the impact of investing in sexual and reproductive health care worldwide. We're going to start first on the Adding It Up landing page, which you can access through the QR code or by visiting this website up here, guttmacher.org/addingitup. On this page, you'll find our global report for the most recent 2024 analysis, which provides comprehensive estimates of the need for and impact of sexual and reproductive health care in 128 low- and middle-income countries. In addition, you'll find our policy analysis, which translates this data into actionable insights for funding decisions and advocacy efforts. But today, I'm going to focus on our Adding It Up tools, which really bring our data to life. We're going to start with our country profiles. These are a great resource to explore if you're interested in diving deeply into a country's current sexual and reproductive health landscape. The country profiles compile evidence from the Adding It Up study in the areas of contraceptive use, maternal and newborn health access, the health impacts of fully meeting the reproductive and maternal health needs of all women of reproductive age, as well as the investment required to both maintain and scale up sexual and reproductive healthcare. They also incorporate model-based estimates on unintended pregnancy and abortion for 150 countries from another global project at Guttmacher. So we'll navigate to the country profiles page, and we'll look at Ethiopia as an example. This is a country where significant progress has been made on reproductive health, but where significant gaps in access remain. To do so, we select Ethiopia from the dropdown menu on the right, and once we do that, the profile will populate with that full picture. This includes, first, current levels of contraceptive use broken out by method type. It also includes estimates of contraceptive need, employing three different definitions for unmet need for contraception, including unmet demand, and it also looks at existing gaps in key maternal and newborn health care indicators. We can also scroll back up on the page and change the tab to look at the tab about meeting the needs for services to examine the impact of and cause of meeting contraceptive, maternal and newborn, and abortion care needs. Here, we look at the impacts on unintended pregnancies, unsafe abortions, maternal deaths, and newborn deaths if all needs were to be met for contraceptive, maternal and newborn, and abortion care in Ethiopia, as well as the cost of meeting women's service needs per capita and the associated cost savings. Overall, the country profiles highlight the importance of services that together support the full spectrum of reproductive health, from deciding if and when to have children, to safe pregnancy, healthy newborns, and sexual wellbeing. Because behind every data point is a person whose life depends on these critical investments being made. The country profiles are a great place to start to explore country-specific data. However, we also have a tool that allows you to make the investment case for increased family planning funding to meet needs for sexual and reproductive health in specific target countries, subregions, or regions. To do this, we're going to head back to the tools section on that main Adding It Up landing page and take a look. The Family Planning Investment Impact Calculator is an interactive tool that allows users to estimate the health and economic impacts of investing in family planning services at the country or regional level for all low- and middle- income countries. Whether you're a policymaker making the case for increased funding, a donor weighing where to direct resources, or an advocate building an evidence-based argument, this calculator puts country-specific data at your fingertips. So we're going to walk through an example of how to use this calculator. For this example, we'll pretend that you're an advocate based in Nigeria preparing for a budget hearing, and you're looking for data on the direct impacts of an increased investment in family planning services. We'll use Nigeria as this example country given its low modern contraceptive prevalence rate and the gaps that exist there in meeting contraceptive need. We click Use the Calculator, and then first, we'll select a currency for our investment. For the example, we're going to use the Nigerian naira. Secondly, we're going to select Nigeria as our target country for the investment. And then lastly, we'll propose an investment amount for a one-year period. For this example, we'll call that 1.4 billion Nigerian naira, which is roughly equivalent to $1 million US. And so we'll enter that amount here and click Add. Then we'll click Next on the screen, and the next step will be to select our preferred language and our preferred currency for the results. So again, we'll use the Nigerian naira for the currency. When you click on Calculate, the tool will generate estimates of the resulting impacts of the proposed investment, including the number of women and couples receiving contraceptive care, the unintended pregnancies, unplanned births, and unsafe abortions prevented, the maternal deaths averted, and the associated cost savings to the health system. These outputs are not just numbers. They're the evidence base that advocates and policymakers need to make the case for investment and family turning dollars and budget decisions into the meaningful on-the-ground impacts that they can achieve. This tool shows us that by investing 1.4 billion naira in family planning services, we would avert 77 maternal deaths and prevent about 5,800 unsafe abortions. That's the kind of evidence that can change a budget conversation. You can also explore these results across different scenarios simply by adjusting the inputs. The tool also outputs various graphics that you can use for your own materials. And the tool isn't just for modeling new estimates. It also works in the other direction. If funding for family planning is being reduced or threatened, you can enter that amount and read the results as what would be lost. The additional unintended pregnancies, the maternal deaths that would no longer be averted, the cost savings that would disappear. It's the same evidence-base applied to the questions that we're confronting right now, particularly around donor funding for family planning. These tools, the Family Planning Investment Impact Calculator and the country profiles are free, publicly available, and designed to put Guttmacher's data directly in the hands of the people who need it most. We encourage you to explore them, share them, and use them to make the case for investing in sexual and reproductive health care worldwide. And lastly, you can scan the QR code on the screen to visit our OSF page, which includes our methodology report, datasets, Stata do files, and appendix tables. We hope you find these resources valuable in advancing your own work. Thank you so much.

Speaker 1: Thank you so much, Beth and Chelsea and Jess, for that comprehensive overview and for taking the time to ground us in the latest evidence on need, impact, and cost. Before we move on to our next speaker, I'd like to extend our deepest appreciation to our Adding It Up 2024 donors, including the Gates Foundation, the governments of Canada and Norway, and the Children's Investment Fund Foundation. It is my utmost pleasure to now welcome Amos Mwale, Executive Director of the Centre for Reproductive Health and Education. Amos will help us bridge the gap between evidence and action, sharing how these data can be used to strengthen advocacy, inform in-country policy and funding decisions, and ensure that key priorities remain on the government's agenda even in the face of financial constraints and geopolitical negotiations. Over to you, Amos, and thank you.

Speaker 5: Thanks, Oni, and good morning, good afternoon, good evening. I must, first and foremost, say thank you so much to you, Guttmacher, for the tools that are even making us as advocates very excited. You know with the current growing number of anti-choice it's really needed that this information and data is critical at this time to actually show the actual investment, the gains, and how we can utilize that data. I think a number of stories have been spoken about, but I think it's critical that when you use the current tools, you are able to show the evidence that is so powerful in terms of advocacy. So when you, you look at the, the issue, advocacy requires that you have the actual data, that data is very credible, and it's linked between the action and the ask that you are developing. We have seen on the number of examples that have been given in terms of how unmet needs for women can actually cost them either not get into employment or how young women cannot stay in school. So how do we ensure that the investments that our governments are actually putting in are showing results? The tools have currently shown clearly how we are able to see and identify priorities to ensure that the decision-makers understand the difference between the data that is being produced and how you are linking it to the ask. So for us as advocates, in most cases, we've been asking for evidence, and this evidence just comes at the right time. So when I was listening I was so excited that, you know, when you look at RH, mostly we need to start framing it as an advocacy issue for not only health, but an issue that focuses on economical and developmental priority. In that way, I think we'll be able to see more evidence being translated into very simple and compelling messages for our decision-makers to use, either at parliament, either at policymaking. I want to give you a typical example of how evidence in such manner is, is being used. Like for instance, in Zambia, you find that you might have allies either at parliament level or at the technocrats level, in this, in this case at ministerial level, but not everyone agrees with what you are actually presenting, even in terms of a policy. Not everyone agrees that actually family planning, huge investment. So with the calculator, you are able to show exactly how the investment is being used, and it's actually calculating, the good part is actually calculating in your local currency and changing it from dollars and how much you're saving and how much return of investment actually you are making when you use the, the calculator. I want to give you another example. When, when we came back from the family planning conference late last year, the permanent secretary in the Ministry of Health actually did gather his staff to show them how the calculator is being used and also show them how the impact is being translated into the actual gains. So everyone now in the ministry and as advocates are excited to be using it and showing how that investment actually can work. So with the data being clearly linked to the policy that we are asking, or the ask that we are asking, then it becomes easy to actually form very actionable interventions at country level as both advocates, researchers, and the people who are making decision. In that way, it's very easy for you to follow. It's also very easy for you to see exactly which tool you are using and you're linking evidence to the actual programming. As I conclude, I want to mention that I think the challenge, the key challenge that we have been having is not lack of evidence, but it's ensuring that the evidence that is being gathered is being used to translate into either a, a policy or to show the gap between the actual implementation and the change in the implementation. So with these tools, we are able to clearly link the two, between the gap, the policy implementation, and the intervention that is being done. So as advocates moving from evidence for advocates means that we need to be very strategic. We need to use the data-driven and solution-oriented. In that way, we'll be able to see more policymakers listening to us and then also translating the evidence that we are seeing into the actual implementable solutions. Thank you so much. Oni.

Speaker 1: Thank you. Thank you so much, Amos, for your excellent answer and for sharing your experience with government advocacy with us. And we really celebrate the Zambian government's commitment to family planning, their pledge, and their willingness to see this through. We know that you have shown us the role of this evidence in guiding national and regional advocacy and in addressing challenges amidst significant financial constraints. I am now extremely pleased to welcome Aparajita Ramakrishnan from the Gates Foundation, who will offer her reflections on the importance of sustained investment and cross-sector collaboration in advancing sexual and reproductive health and rights. Over to you, Aparajita.

Speaker 6: Thanks. I'm just turning my video. Give me a second. There's a lag, sorry. Can you see me? Can you see and hear me?

Speaker 1: Yes.

Speaker 5: Yes.

Speaker 6: Perfect. Great. So thank you to the team at, at Guttmacher and to all of you for, for being here and and having me, having me join you. I mean, it's a great pleasure to join this team, I have to say. For those of you who don't know me but hopefully one day you will you know, data is something that is extremely near and dear to my heart. And and I think the fact that this sector has the benefit of an organization like, like Guttmacher is really an incredible It's an incredible asset to the sector, and it... The sector is lucky to have an like Guttmacher here today. You know, I mean, there's so many partners also who work with Guttmacher, but this, but this ability to kind of draw data together and, and have a very functional advocacy approach that is evidence-driven is something that's crucial, as we all know, as interest, but also resources are constantly waning and under pressure. So first again, a big thanks for convening this discussion. I've been listening carefully, although I have say, I think many of these pieces of data I had seen earlier, but it was good to see it all wrapped up here. And I think the, the tools that are coming out and emerging, you know, the use cases Amos is mentioning, but also, it's just the, the kind of ability to quickly be able to adapt a tool for advocacy use. This is really something powerful that that adding it up brings. You know, our community has known for a very long time that, you know, access to voluntary family planning is one of the most high impact investments, but having the skin and bones around this, this entire framework is really, really helpful, showing the cost the, the the scale of the, of the need, which was established clearly up front here today. The, the cost of meeting it, and I'll come back to that, which I think there's, there's more work to be done, but good, good strides in that direction. And then the return on investment. I mean for anyone looking to make a dollar of investment, this is certainly a place where you know, you can, you can, you can you can see the return very clearly. And I think we'll get more sophisticated in trying to articulate all these three pieces, but the fact that we have such robust assumptions and data already starting us off in this, in this space is, is really a, um, a good kind of clarity for us especially in this moment where we're trying to cut through a lot of clutter to get messages across to key stakeholders. I think governments are facing fiscal, really tough fiscal decisions at this point. Financing is tight. Attention from people you know, is, is waning and/or it's absent because there are just too many calls on a given country to allocate $15 for this and another $8 for that, and another $2 for that, and another $12 for something else. And at the end of the day, each dollar has a trade-off that is presented to a given country. So, the power of the advocacy and the simplicity of the message, but also the, the I would say the simplicity of the of the calculation is, is pretty important. And I'll come back to that on the costing piece. I think when we think of costs in family planning, the, the way I would look at it is, how how it's not how much family planning costs to deliver, but how little can it cost to deliver? And I think this is a shift in the framework, which adding it up and, and the next iterations and the, and the future datas that, data that come out of this sector need to try to, to, to try to address. Because I think resources are not abundant. The systems and program costs that we look at and say, "Oh, that's a big number," we have to think about how do you either shrink those or how do you cost them out such that actually the real cost is, is a, is a fraction of what that is. I think the idea of reduction of costs and a focus on reducing cost is also something crucial, and I think Guttmacher will play a very, very important role in hopefully helping us advance our thinking on this as a sector. Because as we move forward into a space where you know, countries in Africa, Sub-Saharan Africa and Asia are facing huge budget constraints, so creating a pathway for funding the essentials will be very crucial. And this is something that I'm very, very confident that this, the group of people here plus the leadership of Guttmacher can really enable for us. I think in terms of the impact of FP, I really am preaching to the choir, I assume, so I won't need to restate, but just the tremendous benefits, both economic, social, and financial at a, family micro household level are just, are just tremendous. And I think the, the fact that there are ways that you can use the tools that Guttmacher and team have created and I, and the consortium on impact have created, it's really fabulous to see. I think we need to be able to articulate the value to both high income countries and lower income countries and middle income countries in, with equal ease on exactly what needs to be funded and how much that costs and for how many people and how to deliver it. So, I think, you know, this is a simple call to action. Let's use the evidence we have. Let's build on better evidence. Let's try and look at costs with a really, really keen eye to reducing them, but also disaggregating them better. Let's use them to inform national planning. Let's help using it, use it to, to inform investment decisions and policies to strengthen advocacy and to actually ensure that services go where they are most needed, and to, and reach women and families who most desire it. So, I think the evidence is clear. Return is proven. The imperative is, is to invest. Let's try and see how little family planning can cost to deliver. So, thank you very much. I'll pause there.

Speaker 1: Thank you so much, Aparajita, for your reflections. They are really, really well-founded, and you are right. Everything you said speaks of the critical rule of sustained investment and partnership and making sure it gets to the last mile and to the woman on the ground in her country, because all of this will help us advance sexual and reproductive health and rights. And thank you so much for highlighting the role of evidence-based approaches and how we really and truly need cross-sector collaboration across ministries of health, ministries of finance to drive the collective action. Thank you all so much for staying with us and for listening and engaging in today's presentations. You have been very active participants. We are very excited to have all your questions in the chat. As a reminder, if you have more questions, please submit them using the Q&A feature at the bottom of your screen. If you can't find it, please click on More, and then you should see that box, and we're going to start to address some of the questions that you have posed to us during this session. All right. So, I'm going to read them out and then I'm going to call on my colleagues to and I'm, then I'm going to call on my colleagues to give answers. I'm going to take a couple of, questions that I think are coherent and come together. One of the, one of the factors contributing. Sorry, give me a minute. Okay. One of the factors contributing to unmet demand must be dissatisfaction with the products that are currently available due to side effects, undesirable procedures to administer experience while using. does the investment amount proposed to fill the unmet demand include the cost of developing novel contraceptive options? And I'm gonna put three questions in the group because I think Beth will be able to speak to them properly. The second one is, increase in contraceptive demand through information, education, and communication has long been an important component of family planning programs. Does focusing on unmet demand over unmet need, which is the traditional indicator, ignore the powerful potential to increase people's desire to use contraceptives through improved knowledge and awareness? And then the third one in this bucket is, is unmet demand the same as intention to use? Beth, I think that's a good one for you.

Speaker 2: Yeah. These are great questions, and I think we wanna dive in 'cause it's a new indicator we're talking about. We wanna make sure everyone really understands it. So let me sort of explain to answer, I think it was Karen's question that came in, and this question of, is it the same as intent to use or not? I'll sort of describe how we measure it and then answer the other two questions that came in. So among people who are not using a contraceptive method, either modern or traditional, in our current surveys, and for a number of years now, they've been asked, "Do you want to use family planning at any point in the future?" Sometimes there's time-bound questions, but it is a, "Do you want to use family planning at any point in your lifetime?" And so what we do is we look at, okay, among the 214 who had an unmet need for modern methods, then there's the 75 million who used traditional. So now we're down to the 139 million. That's who's getting asked this question on their intention to use contraception, and this is at, any point in their lifetime. Then we look at those who said yes or who said unsure, 'cause I think when you say you're unsure, you're saying maybe, you might be open. So these are people who either want to or who are open to using contraception in their lifetime and in the future, and so that's who's being classified as having unmet demand. That's the group that we have, and we're able to measure that with our current data that we have. I think there was also a question of, how available is this data and the coverage for it? Over 50% of and middle-income countries have data available that allow us to construct country measures of unmet demand. When data is missing, we impute that using sub-regional averages. So when countries don't have that survey data available, we have to make some assumptions and we use some of that sub-regional data. But I think when we're focusing in on that 78 million with an unmet demand, we're saying this is where we focus on for financing for contraceptive services and care provision. So that's like the, what do we need to cost to expand care now? We are not saying ignore the group that says that doesn't have an unmet demand. We need to understand them better. When someone says, "I don't wanna use family planning at any point in my lifetime," it could be, "I have full information and I have agency and autonomy in making that decision, and this is the decision I wanna make." And we say, "Great. That is your right. That is your choice." But there are people who might feel like I'm saying, "I don't wanna use family planning because my partner told me that I'm not allowed to and I feel like I'm not enabled to," or, "I only know of certain methods and I don't know of ones that might meet my my life circumstances better." And so I think further research and diving into that group and understanding sort of what is the information and awareness campaigns and women's empowerment work that needs to take place to better meet that group's need is really important. And so we're not saying ignore them; we're saying we gotta cost contraceptive service care provision for this group, and we need different interventions and programs to understand the other group. I think just the last piece I'll, I'll add in is there was a question of, are we taking into account the, the funding that's needed to bring to develop new contraceptive methods? 'Cause there's a lot of people who want sort of qualities in their methods that aren't in that are available to them today, and we're not including that in Adding It Up in our estimates. We're looking at sort of costing out current method provision, but funding R&D and work on new contraceptive methods, including male contraceptive methods, is really important right now.

Speaker 1: Thank you so much, Beth. I think that was an excellent answer. It's never an either/or with unmet demand or met. And it's, it's, we're trying to include everybody, but make sure we're respecting people's needs as we expand the bucket. I wanna hold on for you for one more minute, Beth. So given the 78 million women with an unmet demand for contraceptive care, how should governments prioritize reaching these populations, especially in contexts where resources are extremely limited?

Speaker 2: That's a really good question. I mean, I think that, you know, unmet demand, we've been talking about it as this idea of, like, it's a strategic starting point. So I think, for a long time, our field was talking about financing and trying to push for unmet need for modern, modern as the target. So already we're saying, okay, let's be strategic. Let's concentrate resources on those with the most pressing need. And so we can think about, what do we need to do that? And there, there are two pieces. One is expanding to meet their need, but we also need to make sure that we are shoring up and protecting current contraceptive care users' access too. So we need to think about things like supply chains and expanding method mix, reducing stockouts, ensuring there is sustainable and diversified funding so that we're protecting the services that are there, so that when we expand to meet unmet demand, we're building on a strong base. And so we need to sort of be thinking about both of these things. And I think to sort of tie this into Aparajita's comments at the end, we can think about how to do this more cost-effectively. We can think about community-based distribution. Task-sharing is a really powerful way where we can both expand access and reduce costs simultaneously by really ensuring that we're pursuing the most efficient models of care that can reach the most people. And so I think it is thinking about this whole systems approach of, what are all the different things we need to do to protect care to allow us to expand it and to do it in a really cost-efficient way?

Speaker 1: Thank you so much, Beth. And, and I'm gonna add on and advocate that if, if we as a community and as governments and advocates are able to cost out the most effective ways, then there are other communities, like folks in humanitarian and conflict-affected and climate settings, that we extend the dollar to get to because we recognize that there is significant cost in reaching them. But then making sure we're being efficient with costs in fairly stable populations then allows us to extend finances that way. Now I'm gonna move to my colleague, Chelsea. I have two questions that I'm going to queue up for you to take, and one has to do with data inputs and is around the DHS. And it says, "Given changes to global support, to support for global data infrastructure, such as changes in the funding for DHS surveys, how is Guttmacher thinking about continuing to work on the Adding It Up model moving forward?" And I'm gonna jump in and add a second one, which I think is really interesting and I'm excited for you to talk about, because it says, "What are the requirements to replicate this kind of study in Rwanda?" Over to you, Chelsea.

Speaker 3: Great. Thank you so much, Oni, and, and thank you for these questions. Absolutely the, the global data infrastructure is changing rapidly. The, there's, you know, I think we could spend an entire webinar on that topic alone. It's a very big one. I'll, I'll start with a bit of good news since that feels more rare these days. The good news is that representatives from ICF who are involved with conducting the DHS surveys did recently indicate that DHS survey output is expected to remain roughly comparable to recent years at least for the next couple years, at around 10 new data sets per year, you know, plus or minus a few. So we're encouraged that with some recent support coming in, those, those data will continue to come out. Specific countries are still mobiliz-, who are still mobilizing resources for their survey might face longer gaps between surveys but, you know, adding it up, we'll continue to incorporate all new DHS surveys that do come out as it, as it completes annual updates. And Adding It Up does also draw upon other data sources, in addition to DHS surveys, such as MIX surveys. We'll continue to do that. We haven't heard that there's any specific cuts to MIX at the moment, although certainly there are overall cuts to UNICEF right now, so we're monitoring that situation closely. One thing that Guttmacher is currently very actively exploring is finding ways to apply the Adding It Up model at the subnational level. So currently, you know, in the results that you heard about today, the Adding It Up model provides estimates at the global, regional, sub-regional, and country levels. But we were very interested in taking on subnational work driven by a desire to really engage in budget conversations at a more granular level. And modifying the model in this way and applying it at the subnational level also opens up the possibility, in some cases, of incorporating data that are collected within countries that could supplement or potentially replace data from some of the large international surveys. So we're currently partnering with our colleagues at CRED in Nigeria to generate Adding It Up estimates for four Nigerian states. This includes Lagos, Bayelsa, Kaduna, and Kogi. And we're hoping that our results from this work will be available around the end of this year or early next year in a, in a peer-reviewed publication. So we're excited, you know, for testing out this approach to apply the model at a subnational level. And I think that, you know, relates to the question that you mentioned in terms of, what would be the requirements to replicate the same study in, in Rwanda? I think to that person I would say, please explore on our website the country profiles that are available. You could you could pull up a country profile for Rwanda or any other country that's in there. These profiles include model-based estimates on unintended pregnancy and abortion. They provide a snapshot at the country level on contraceptive use, maternal and newborn health services health impacts of meeting reproductive and maternal health needs, et cetera, and, and the investments required to maintain and scale up that care. So you can get that country level look, you know, already on our website. If you are interested in you know, exploring a partnership around application as we're doing in Nigeria at the subnational level, please reach out. We're happy to talk. And yeah, more broadly, you know, at Guttmacher we'll be continuing to monitor changes in the global data infrastructure and having ongoing conversations about the adaptations that might be needed to, to keep this work as relevant as it possibly can be. Thank you.

Speaker 1: Thank you so much, Chelsea. And like Chelsea said, if you'd like to reach out, please reach out to any of us on the call and we'll put you in charge with Chelsea and the team. I have a question that I, I think really speaks to some of the points Aparajita was raising and I'd like to pose to her. It says that this kind of data is certainly valuable, but it raises a critical feasibility question. Given the severe fiscal constraints many governments are currently facing marked by elevated debt to GDP ratios, slowing growth, and inflationary pressure driven in part by high energy costs, it is unclear where additional domestic financing could be realistically sourced. Without a credible pathway for expanding fiscal space, expectations for increased domestic funding may not be grounded in current macroeconomic conditions. And then how do we respond to this situation? Over to you, Aparajita.

Speaker 6: Yeah, thanks. I mean, that's exactly, that was it's more the you know, the, you stated the problem where I've tried to say that, you know, we need to really retrofit the solution. So the solution being, you know, in in some cases it's to really start from a very low cost base and say, okay, the commodity is at the core of the intervention, but what around that do you need to be able to deliver that service or commodity or product to a woman or a family in need, and think of it very minimalistically. And I think this is a very different approach than health in general has taken to costing. It will require us as a, a costing community to rethink how we look at our priors, but I do think when governments are faced with, you know, a $15 per capita looks small to maybe someone, but I imagine to an LMIC government on a per capita basis, that's, that's an unaffordable in some, to many people right now competing with, you know, economic crises, banking failures, you know, all kinds of things that are being happening, oil price hikes that are happening right now in very real time. And, and there, and ballooning debt, as, as someone pointed out. So we have to think creatively as a community about how we can reduce what we say governments really need to deliver FP based on what we know is possible. And I think here as a community, we have to mine back best practices to say where have we very cost efficiently, and we'll come back to effectiveness later, but just even cost efficiently in terms of reach, done a good job of per CYP and really in, in our community we can use the CYP framing because it varies widely between short and long acting methods. So you can say on a per CYP basis, where have we as a community excelled? Where have we managed to deliver at an extremely low cost per user, not per capita, right? And that I think might be something that then helps make the shock of the number, the sticker shock more manageable for an LMIC government looking to finance it. But then there's a question you're asking which is about where does that money come from? Which is the second problem to solve, which obviously requires domestic financing plus donor money. Donor money is on the wane, so how can we ramp up the effectiveness of, of, of domestic financing? You know, the, this we are working with the World Bank right now to try to open up some, some commodity financing The the World Bank's been a great partner on that, but I don't think that'll be enough. The question of how then countries can reallocate, but again, if you give them a big number, they can't. So, what is the bare minimum, the essential minimum that needs to be funded to motor an FP program in a country? And I think if we go with big numbers, we will get sticker shock and countries won't be able to figure out what to do. So, I do think it's on us as a community to try to think about how little, the bare minimum needed, to actually fund a very robust and rigorous program where you don't compromise on preference aligned FP, on actual access, on voluntary uptake, on good quality counseling, none of that. But what is the bare minimum cost of that? Not the maximal, you know, loaded, fully loaded versions of costs that we've seen in the past. So, I think it's a nuanced thing. It's on us as a community. This is something we are very seized with. We've had discussions recently with leadership on this. This view of, you know, and, and, and in, in many ways, FP is at the leading edge of this, because there's been some, some great work on costing done in the sector. So, I think the onus is on us as a community to come up with data and figures and costs that are actually manageable, bite-sized enough that countries can actually even think about funding them, given all these, you know, very heady competition spaces in which they are currently. I'll pause there. And I have to log off, so thank you, Oni.

Speaker 1: Thank you so much, Aparajita, for that answer. And seeing how Aparajita was sort of leaning into costing approaches and the work we've got done, I think we do have an interesting cost and methods question that that I wanna pose to Beth, just so she gives some insight on that. It says, "How did you estimate human resources for health costs just for FP? As we know that service delivery is integrated at point of care, so how do we differentiate between HRH costs for anything?" And as someone who has worked in health profession as a physician, I know it's often the same provider delivering multiple things, but I think let Beth give some insight into how we're able to isolate or cost out that portion, specifically for family planning.

Speaker 2: It's nice, it's a nice segue actually from her, Aparajita's comments, 'cause it's how, how are we doing this costing work and sort of getting into the methods of it, 'cause that's the space where we can start to, to do some modeling and work at some, look at some of these details and explore different, different costing, different ways to reduce costs and, in ways that work. So adding it up overall use is a bottom up ingredients-based costing. And so we actually have over 100 different distinct treatment interventions that we then build sort of detailed costs for. And so when it comes to health workforce time, we look at the cadre of staff that are offering those services, and then actually estimate specific minutes of their time that they are spending in providing that specific intervention. So, we're costing it out for, for each different type of family planning commodity differently, who's providing that service, how much time would it take? We're including the contraceptive counseling as part of that. And so we're really doing like, a minute based costing assumption. There's other ways that one can allocate health workforce time, doing sort of, you know, time, time analyses and facilities and different ways of, of breaking that out. But our approach in adding up is this bottom, bottom up ingredients-based costing that we do. I will say, we, we publish our treatment assumptions, so those are all available. We can share in, in the chat and, and answering some of the Q and As, the, the methodology report that includes that in these appendix tables, but we have all of those details there for folks to go, go and look at and see, or go apply that in your own country and do your own costing using those treatment assumptions as a starting point. And so we'll just encourage folks to dive into some of those resources.

Speaker 1: Thank you so much, Beth. Amos, are you there? 'Cause I think we have one last question that we're take.

Speaker 5: Yes, I'm here.

Speaker 1: Okay. We have one last question that we're able to take during the webinar, and I'm, I'm gonna read it out and I, I think it's a two, it's a sort of two-part question, so I think there's a part where you're very well poised to answer, and then I will round us up. It goes, "Given the generational timeline for transformative change, what strategies are most effective for cultivating or even sustaining political will and financing for SRHR over time?" I thought it might be interesting, Amos, if you sort of gave us insights from your work in the field on how we sustain political will for investing in SRHR, given that Zambia has been a champion for many SRHR policies, despite pushback internally and externally.

Speaker 5: Thank you so much. That's a very good and great question, Oni. So, for, for me, I think over a long period of time working in the sector, I have learned that dialogue is the key element in ensuring that we sustain SRHR. We need to continuously build the champions. We need to continuously engage the different stakeholders. We need to continuously use the innovative information that we are getting. So for instance we, like we've heard earlier on, we need to continuously speak about the, the importance of showing the cases and the investment. Why is the investment important? Why are we insisting, for example, on keeping the girls in school? Why are we insisting on family planning? Why are we making reproductive health a priority, not only for women, but as a national issue? In that manner, we are consistently speaking the same language, consistently asking for the dialogue and asking for budget allocation and asking in, DRIM, you spoke about domestic resource mobilization, I think that's where everyone else is going. I mean, it's, it's a discussion that we're having with the, the key stakeholders. So for instance, we, we, we've been having this dialogue, you might be aware that Zambia hasn't signed the, the compact, but one of the things why they haven't done that is trying to now bring in the cross-sector. We need to move away from health alone, in two ministries of finance, in two ministries of social development, so that they are able to agree. One of the, the, the challenges we've had over time is not involving the Ministries of Finance when decisions are being made. So for instance, now, the Ministry of Finance for Zambia is actually on top of issues, even to agree on some of the resources that are going to be allocated for the next five years for Zambia's health. Once that is done, and it's been a consultative process, I think it's easy for you to then seek those ones, and you make them as commitment to ensure that you're pushing them, you are following up with the different ministries, you are following up with the Ministry of Health and the technocrats, that the allocated resources and the investment actually meets the priorities of the country. In that manner, you'll be able to sustain the priority and you'll be able to sustain reproductive health. Thanks, Oni.

Speaker 1: Thank you so much, Amos. And like, like all simple questions, Amos has outlined a few key steps to how we can sustain SRHR over multiple generations. And so I'm just gonna repeat it back, but then I'm gonna add one thing. Amos has told us that you need to embed it in multi, in a multi-sectorial approach. It needs to be across sectors, finance, education, universal health coverage. Where possible, try to embed it in legal frameworks. Because once you've put it in the law, it's very hard to unlock it. Aparajita had talked about diversifying money, and Amos had built on that. We need to look at multiple sources and be creative in how we mobilize finances. And Amos talked about, about multiple stakeholders broadening the coalition. But one thing I really want to add is that whether you're a researcher, or you're a donor, you're an advocate, we're all part of a large movement. And so we need to continuously invest in the next generation of advocates, those who will hold the government accountable, the people who will do domestic resource mobilization, the people who hold gender equality as a value. Because when we look historically, the countries that have been most resilient, where SRHR and family planning and other aspects of SRHR have survived over generations, have combined all of these tools. Because we don't want to win one policy fight or one budget cycle. We really want to build out an infrastructure that will sustain progress at the country level over time, regardless of who is power, who's in power. I wanna say a big thank you to everyone for being here today. I know that my colleagues have been answering some of the questions in the chat. Thank you so much for submitting questions, for engaging in this discussion. We hope you found our presentations and the insights from our speakers, Beth, Chelsea, Jess, Amos, and Aparajita deeply helpful and inspiring for your work in advancing sexual and reproductive health and rights. We'd like to remind you that you can access the Adding It Up resources, the Family Planning Impact Consortium Tools, and country-level data by scanning the QR code on your screen. I'm gonna wait for my colleagues to put that up for minute. If it's coming. And all the tools that we shared with you today and some of the others which you can look for on our website are designed to support your advocacy, your policy, and your funding efforts in practical ways. We are deeply grateful for your time. In a period where there are many meetings to do with today's landscape, we're deeply grateful for your attention and your commitment to evidenced-based action. And I wanna say a big thank you and, and ask the audience to give a round of applause to our amazing speakers for sharing their expertise. Thank you all so very much. With that, we'll officially close today's webinar, and we wish you all a productive and impactful day ahead. And please do reach out if you have, any other questions. Thank you all.