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Kalila Jaeger, Zoe Johnson
March 1, 2021
Watch a recording of the Donor Tracker webinar featuring the Kaiser Family Foundation on_ _donor funding for sexual and reproductive health and rights.
Of all the plans laid out in the Sustainable Development Goals (SDGs), SDG 5 ("Achieve gender equality and empower all women and girls") is one of the most ambitious. Throughout human history, half of the world’s population has been counted out, their intellectual and economic contributions disregarded, their bodies abused and commodified. Considerable progress has been made towards empowering women globally to live their lives autonomously. Since the adoption of the 1995 Beijing Platform for Action, 131 countries have enacted 274 laws and regulations in support of gender equality. More girls than ever before are in school, and maternal mortality rates have fallen by 38% globally. Still, massive challenges remain. Nowhere in the world are women born into full equality and, in many places, to be born female is to be born a second-class citizen.
We have already entered the final decade before the SDG’s 2030 deadline. However, progress on SDG 5 lags across a range of indicators, including targets to eliminate violence against women and girls and ensure universal access to sexual and reproductive health and rights (SRHR). To level the playing field between men and women globally will require a massive and focused international effort.
In 2020, in recognition of the importance of SDG 5 in the Decade of Action, the Donor Tracker added Gender Equality to our analyses of 14-major Organisation for Economic Co-operation and Development (OECD) Development Assistance Committee (DAC) donor markets, allowing users to compare donors’ commitments and disbursements to gender equality efforts. In addition, the Donor Tracker is publishing a series of three Insights pieces, which will provide readers with a more detailed analysis of three main elements, or ‘pillars’ of gender equality endeavors: namely, funding for women’s economic empowerment; efforts to end gender-based violence; and the fight for sexual and reproductive health and rights. This third piece analyzes existing research and newly released 2019 OECD data to assess how donor countries are approaching and, in many cases, falling short on efforts to promote sexual and reproductive health and rights in their global development programs.
Sexual and reproductive health and rights, or SRHR, is a critical element of gender equality. SRHR refers to several, interconnected freedoms and rights: the freedom to choose if, when, and how to reproduce; the right to access comprehensive sexual and reproductive healthcare; and the right to a safe and satisfying sex life with whichever partner or partners a person should choose.
At the 2021 Generation Equality Forum, donors and stakeholders will come together in a framework convention for gender equality, launching concrete, ambitious investments, and policies. Promoting universal access to SRHR resources must be a top priority in the commitments that emerge from the Forum. SRHR is crucial for people of all genders; the freedom to control the functions of one’s own body is a fundamental right, one without which all other types of freedoms fall away. Inadequate access to condoms can lead to the uncontrolled spread of sexually transmitted infections (STIs or STDs) including HIV, putting people of all genders at risk. For people who can become pregnant, lack of access to SRHR resources can lead to involuntary pregnancy, potentially turning young girls into mothers decades before they would have chosen this responsibility, often cutting off access to school, paid work, the chance at life with a chosen partner. This can undermine their ability to benefit from other efforts toward improving their social and economic mobility.
We still have a long way to go to achieve universal SRHR for people around the world:
To make matters worse, these major challenges to SRHR access have been further complicated by the COVID-19 crisis. The pandemic has strained health systems globally and undermined women’s access to SRHR services. Combined with an uptick in domestic violence, this means many women are facing crises of reproductive autonomy. Experts have been warning since the outset of the pandemic that a failure to prioritize SRHR services throughout the outbreak would have dire consequences. UNFPA predicted that 47 million women in 114 low- and middle-income countries would lose contraceptive access in the first six months of lockdowns resulting in seven million unintended pregnancies. For every three additional months of SRHR service disruptions, they estimated up to two million additional women would lose access to modern contraceptives globally, with unintended pregnancies increasing steadily throughout.
We likely won’t know the full measure of the COVID-19 pandemic’s consequences on SRHR access for several years to come, but understanding the funding landscape over the past decade can help inform future-oriented discussions and advocacy to ensure that donors continue to provide adequate support for SRHR through their official development assistance (ODA) despite the increased strain caused by COVID-19.
This ‘Insight’ draws on the latest OECD data to track ODA being spent on SRHR. It asks:
The data for this analysis was drawn from the OECD’s Creditor Reporting System (CRS) database, which covers development assistance provided by the 30 Development Assistance Committee (DAC) donor countries, 20 non-DAC donor countries, and 46 multilateral donors. When reporting ODA to the OECD, donors mark their funding using sector and purpose codes that classify the issues being addressed by the projects their development assistance is channeled toward.
In accordance with the methodology used in the Partnership for Maternal, Newborn and Child Health’s 2020 report, ‘Funding for SRHR in Low- and Middle-Income Countries: Threats, Outlook, and Opportunities’, this analysis of SRHR looks at funding flowing to sector code 130: ‘Population Policies/Programmes & Reproductive Health’. This includes the following purpose codes:
To illustrate the scale of funding to SRHR, this Insight also refers to “total health ODA”. This includes funding for sector codes 121: ‘Health, General’, 122: ‘Basic health’, 123: ‘Non-communicable diseases (NCDs)’, and 130: ‘Population Policies/Programmes & Reproductive Health’.
Following the broader analysis of overall funding for SRHR, this piece analyzes ODA to the three highest-funded purpose codes within ‘Population Policies/Programmes & Reproductive Health’: STD control including HIV/AIDS, reproductive health care, and family planning in more detail.
Overall, the SRHR sector saw gradual increases between 2009 (US$9.3 billion) and 2013 (US$10.9 billion), then a dip in 2014-2015 before a peak in 2017 of US$11.1 billion in total ODA (including bilateral ODA from OECD donor countries and ODA from multilateral donors). In 2019, after two years of decreases, total ODA (to SRHR was US$7.9 billion (see Figure 1). The reduction in funding since then is, in large part, attributable to what appears to be a decline in funding from the US, particularly in the STD control subsector. However, US funding to the SRHR sectors has not fallen as sharply as 2019 OECD data appears to show. The US’ 2019 totals in the CRS database are known to be low for several reasons, but primarily because disbursements (particularly to HIV projects) have not all been reported yet. New releases of CRS data in the coming months will reflect updated US totals. It is important to note that US disbursements in the SRHR sector are not reflective of political commitments. A number of factors may cause US disbursements to fluctuate over several years, but funding provided annually by US Congress for HIV projects (pictured here as STD control) and for family planning and reproductive health projects have remained stable for several years.
Bilateral ODA from donor countries accounted for 79% of total SRHR funding over the 2009-2019 period. This includes both DAC and non-DAC donors, although the latter, which are not obliged to report ODA to the OECD, represented only 0.01% of funding. Multilateral donors (including the EU Institutions) contributed the remaining 21% (see box: ‘Top multilateral donors to SRHR’ for information on the top multilateral donors to SRHR).
The US is by far the most important bilateral funder for SRHR, making up 59% of total SRHR funding (US$4.6 billion) in 2019 (see Figure 2a). Meanwhile, the UK allocated US$554 million to SRHR in 2019 and the Netherlands provided US$255 million.
The Netherlands, the US, and Denmark spent the largest shares of their total health ODA on SRHR in 2019 (see Figure 2b). In relative terms, the Netherlands topped the charts in terms of the emphasis it places on SRHR services, directing 85% of its health ODA toward SRHR projects. The US places second (71%), followed by Denmark (60%), Sweden (51%), and Canada (45%). These countries spent much more of their health ODA on SRHR than other DAC donor countries; in 2019, donor countries on average spent 23% of their global health ODA on SRHR projects.
The following section analyzes SRHR funding trends and policies of some of the most important donor countries in absolute and relative terms, namely: the US, the UK, the Netherlands, Sweden, and Canada.
For further analyses of funding for SRHR, recommended readings include:
US ODA for SRHR has dwarfed funding by all other donors for at least the last 10 years. In fact, US ODA to SRHR, particularly in STD control, is on such a different scale than any other bilateral donor that a chart depicting them together is unreadable. For this reason, US funding flows to the total sector and to the STD purpose code are depicted separately from other donors (see Figures 3 and 6).
The scale of the US’ contribution to SRHR is less representative of a strong political affinity for the topic and more of the overall size of the US’ large global health budget. Because of the US’ importance for SRHR funding, US electoral politics have had an outsize impact on the landscape of the SRHR sector more broadly.4 Sex, gender, sexuality, and especially abortion are highly polarizing topics in the US. The association of these issues with SRHR funding, in particular family planning, has made ODA to SRHR a wedge issue in American electoral politics; Republican administrations repeatedly introduce policies restricting funding for family planning programs and Democratic administrations repeatedly roll back limitations to restore them. Despite political division over some types of SRHR funding, it is worth noting that US congressional support for ODA to SRHR has historically been bipartisan.
Under the Obama administration (2009-2017), the US’ ODA for SRHR increased from US$6.0 billion in 2009 to its peak of US$7.3 billion in 2017, an increase of 22%. Once in office, President Trump tried to cut US spending on SRHR initiatives across the board. Repeated attempts to slash funding to the President's Emergency Plan for AIDS Relief (PEPFAR, the US’ flagship program to combat HIV/AIDS) by US$800 million or 20% were dismissed by Congress, as were attempts to cut support for maternal, newborn, and child health (MNCH) by US$80 million. Of all SRHR subsectors, though, family planning came under the harshest, most enduring attack as the Trump administration attempted to cut US ODA to the subsector through a variety of means, only some of which were successful (see ‘Family Planning’). The reinstatement of the US’ “global gag rule”, disqualifying any organization which provides or refers out for abortion services from receiving US global health funding (see Box 2), caused a ripple effect across the sector, as other donor countries scrambled to fill the sudden need for funding to support the full spectrum of family planning services. Trump also eliminated all support for UNFPA, prompting other donor countries, particularly Norway and Sweden, to increase their spending.
Newly elected US President Biden has already rescinded the global gag rule. Biden also ordered the US’ withdrawal from the Geneva Consensus Declaration, an anti-abortion declaration signed by 34 conservative countries. So far, Biden’s first budget proposal has been significantly delayed but once published, it will provide more information about funding levels to global health projects writ large, as well as SRHR and family planning specifics, and give a better picture of Biden’s vision for the US as a provider of SRHR ODA.
The Mexico City Policy, also known as the ‘global gag rule’, is a US policy prohibiting international organizations from receiving US funding if they provide abortion services, referrals to the same, or advocacy for abortion law reform, even if they use other, non-US funds for those programs.
The rule was first enacted in 1984 under Republican President Ronald Reagan and since then it has been rescinded and reinstated by every administration in turn along partisan lines. It has been active for 21 of the past 36 years, significantly shaping US foreign assistance for global health. Under the ultra-conservative Trump administration, the policy became even more restrictive than under previous Republican leaders, extending beyond family planning groups to apply to child and maternal health, malaria, nutrition, and PEPFAR programs, among others, ultimately affecting an estimated US$7.3 billion in global health funding in Fiscal Year 2020 alone. By comparison, the policy under George W. Bush, the last US president to employ it, had applied to about US$600 million in total family planning funding.
A study from International Women’s Health Coalition two years into Trump’s expanded global gag concluded that the policy had had an especially devastating effect on the most vulnerable populations, disintegrating vital health services and limiting access to critical community providers.
Studies have shown that individuals seek out and get abortions, even in settings where they are restricted or banned. Unsafe abortion, which accounts for up to 13% of maternal deaths annually, is overwhelmingly concentrated in low-income countries. The cost of treating the 7 million women who are admitted each year to hospitals for major complications arising from unsafe abortion is approximately US$553 million, annually: more than half of all donors’ total expenditure on family planning in 2019.
The UK’s allocations to SRHR have seen significant highs and lows over the last decade but have ultimately trended upwards from US$461 million in 2009 to US$554 million in 2019, an increase of 20% (see Figure 4).
As the second-largest bilateral donor to SRHR projects, the UK has played a major role in the international effort to maintain full-spectrum funding for SRHR as the US under the Trump administration withdrew funding from crucial pillars of the sector.
The UK’s 2018-2030 Strategic Vision for Gender Equality names "promoting universal sexual and reproductive health and rights” as one of five strategic priorities. The UK has prioritized SRHR in its COVID-19 response, by committing £10 million (US$13 million) to UNFPA’s COVID-19 response. In the spring of 2020, the UK signed a joint diplomatic statement with 59 other countries (including the Netherlands, Sweden, and Canada), vowing to protect SRHR and “promote gender responsiveness in the COVID-19 crisis”.
It is unclear whether the UK will maintain such high levels of ODA to SRHR in the years ahead. In September 2020, the UK Prime Minister merged the former Department for International Development (DFID) with the Foreign and Commonwealth Office (FCO), forming a new Foreign, Commonwealth and Development Office (FCDO). Despite reassurances from the FCDO that gender equality, including SRHR, will remain central to its mandate, the department’s failure to formally adopt the Strategic Vision for Gender Equality (introduced in 2018 by DFID) has raised concern among gender advocates.
This concern is compounded by the November 2020 announcement that the UK will only spend 0.5% of gross national income (GNI) on ODA starting in January 2021, rather than the formerly legally mandated target of 0.7%. This, combined with the fall in UK GNI as a result of the economic impact of the COVID-19 crisis, will result in a substantial decrease in volumes of UK ODA. So far, the government has not released comprehensive information about exactly which projects will be impacted by these cuts, but given the scale of the expected decreases, it is safe to assume negative implications for SRHR funding levels as well.
The Netherlands has significantly increased ODA to SRHR over the last decade with funding starting at US$164 million in 2009, peaking in 2018 at US$289 million, and decreasing slightly again in 2019 to US$255 million: 55% more than the 2009 allocation (see Figure 4).
With ‘Sexual and reproductive health and rights’ as one of eight overarching development priorities, the Netherlands is a proven international leader on this topic, with a special focus on family planning and the rights of minorities and vulnerable populations, including sex workers and LGBTQ+ people. The Dutch Minister for Foreign Trade and International Development in 2017, Lilianne Ploumen, founded ‘She Decides’, an international organization established in response to Trump’s signing of the expanded global gag rule, which galvanizes political support for women’s social and political rights to make informed decisions around their sexuality and reproduction. In the first year following the implementation of the expanded global gag rule, ‘She Decides’ raised US$453 million in additional funds (i.e. funds not already pledged or budgeted at the time of the initial pledging conference). Sigrid Kaag, Ploumen’s successor, has continued working to keep SRHR in the spotlight of the Netherlands’ ODA policy.
With the Netherlands’ federal elections scheduled for March 2021, it remains to be seen which changes, if any, are to be made to the country’s strategy on SRHR, but the outgoing government has made an effort to reassure the public that SRHR is still a top priority. Addressing the Dutch parliament in October of 2020, Kaag reiterated that, despite a contracting economy, the government was committed to maintaining budgetary levels in its framework protecting SRHR and women's rights abroad.
Sweden’s funding for SRHR has steadily increased over the last ten years with disbursements starting at US$74 million in 2009, peaking in 2012 at US$129 million, and settling at US$125 million in 2019: a 74% increase over ten years (see Figure 4).
As the first country to adopt a feminist foreign policy in 2014, Sweden has long been viewed as a trailblazer in the field of gender equality generally, and particularly in the world of SRHR, which is one of six objectives of the policy framework. Funding to the sector has been increasing since the start of the decade.
Sweden lobbied aggressively for SRHR to be included in the 2019 UN Political Declaration on Universal Health Coverage and, the same year, released a new government 2019-2023 engagement strategy for the Global Fund, with a focus on promoting SRHR in health system strengthening projects.
Canada has significantly increased funding for SRHR over the last ten years (see Figure 4). With a starting point of US$71 million in 2009, Canada scaled up its allocations starting in 2017 with US$141 million, eventually reaching US$221 million in 2019: 211% growth over ten years.
Health is a cornerstone of Canada’s Feminist International Assistance Policy (FIAP), in particular, SRHR and maternal, newborn, and child health. Canada’s development policy frames SRHR as fundamental to the empowerment of women and girls.
Canada was an active participant in global efforts to blunt the effects of the global gag rule, including through contributions to ‘She Decides’. Canada hosted the 2019 Women Deliver conference in Vancouver, where Prime Minister Trudeau announced an annual commitment worth US$1.1 billion to support women’s and girls’ health for ten years beginning in 2023, with US$540 million dedicated to SRHR annually.
The following section analyzes SRHR funding trends to the three purpose codes within SRHR that received the most ODA over the last ten years. These are STD control (including HIV/AIDS), reproductive health care, and family planning. It also includes links to further readings that provide more in-depth analyses of these issues.
STD control: In the last ten years, almost three quarters of SRHR ODA went to STD control, including HIV/AIDS
The sheer scale of the global effort to eradicate HIV/AIDS and the fact that all HIV-related projects are considered by the OECD to fall under SRHR means that STD control projects comprise the majority of the sector (see Figure 5). In 2019, total ODA for STD control stood at US$5.0 billion or 63% of total funding to SRHR that year.
STD control still attracts the largest share of ODA for SRHR, but funding to the subsector has fallen by 36% over ten years. STD control ODA reached a peak in 2011 with a total of US$8.2 billion, of which US$5.7 billion was provided by the US. In the years following, nearly every major donor country decreased spending on STD control resulting in a loss of US$1.6 billion in over four years and culminating in a 2015 crash (see Figures 6 and 7). Stark reductions in funding, particularly from the US and UK, and a gradual withdrawal from the sector by Germany primarily powered the decrease.
The decline of ODA to the STD control purpose code is also likely a reflection of the success of global efforts to combat the spread of HIV/AIDS and to reduce the number of associated deaths. Mortality rates have fallen by 49% since 2005; however, according to UNAIDS, an additional US$26.2 billion is still needed to meet the global ‘Fast-Track’ targets by 2030.
For further analyses of funding for STD control including HIV/AIDS, recommended readings include:
Reproductive health care is the second most highly funded issue within SRHR, accounting for 16% of total ODA to SRHR between 2009 and 2019 (see Figure 5). In 2019, funding for reproductive health care totaled US$1.7 billion, or 21% of SRHR funding (see Figure 8).
From 2009 to 2015, total funding to reproductive health care increased at a fairly steady rate, reaching a peak of US$1.8 billion in 2015. The largest donor countries to this subsector are the US and the UK, with the US primarily responsible for the influx of funds to the reproductive health care purpose code in the first half of the decade.5 Between 2009 and 2017, the US nearly doubled its spending to a peak of US$707 million, before delays in the disbursement of US funding resulted in a sharp drop to US$560 million in 2019.6
The UK, the second-largest bilateral funder to the purpose code, tripled its spending on reproductive health over the first half of the decade between 2009 and 2015 to reach US$368 million. The second half of the decade saw another decrease in UK spending, with funds dropping again by almost 50% down to US$192 million in 2019.
The Netherlands, the third-largest donor country to reproductive health, has gradually increased funding over the decade, from US$102 million in 2009 to US$174 million in 2019. This is consistent with an increase in Dutch spending in the SRHR sector at large over this period.
For further analyses of funding for reproductive health, recommended readings include:
Family planning ranks third among the top-funded subsectors of SRHR and accounted for 8% of total SRHR ODA between 2009 and 2019 (see Figure 5). In 2019, family planning projects received US$930 million in ODA (bilateral and multilateral), or 12% of total ODA to SRHR. Family planning allocations have increased gradually over the decade, with the US, UK, and Canada as top donor countries.
The US was by far the largest donor to family planning between 2009 and 2019, providing 73% of the total funding to the sector throughout the decade. Although Figure 9 appears to show a marked decrease in US ODA for family planning between 2018 and 2019, this is largely due to the timing of disbursements; in fact, US bilateral appropriations for family planning remained steady during the Trump administration, despite the president's efforts to eliminate or drastically cut funds.
The reinstatement of the global gag rule in its expanded form reshaped the sector as other donors rallied together. The overall growth in funding for family planning in the years following was therefore primarily driven by increased allocations from non-US donor countries (see Figure 9), namely the UK (which nearly tripled funding levels between 2016 and 2019 to US$322 million), Canada (which increased funding to family planning nearly eight-fold between 2016 and 2019 to US$39 million) and Norway (which tripled funding in the same timespan to US$30 million).
The UK, the second-largest bilateral ODA provider to family planning in 2019, spent US$322 million for the purpose code. Starting in 2012, the UK hosted its first yearly Family Planning Summit, committing to spending an average of £180 million (US$242 million) annually until 2020. In 2017, the UK reported that it had so far supported eight and a half million women in accessing modern contraception, and committed to redoubling efforts to spend £225 million (US$301 million) yearly for five years. In a thinly veiled reference to the US’ withdrawal from the sector, the report specifically referred to providing “predictability” to “allow [partners’] long term planning”. Family Planning 2020, a global organization working with governments, civil society, multilaterals, philanthropists, and the private sector was also born out of the 2012 Summit and has since become a key player in the family planning sector.
At the 2019 UN General Assembly, the UK announced a £600 million (US$767 million) package for family planning in low-income countries, a move viewed by many as an open rebuke of the Trump administration, whose delegation at the event had called for the term “sexual and reproductive health and rights” itself to be removed entirely from UN documents. The five-year funding envelope was the UK’s largest ever standalone package for family planning and included financial support for abortion in countries where those services are legal.
Canada also significantly stepped up its commitments to the family planning purpose code in 2017 to address funding gaps caused by the US’ expanded global gag rule, raising its rank among donor countries to the third-largest in the subsector. Canada made two major pledges that year: US$15 million at the 'She Decides' conference, plus US$501 million to be disbursed over three years to fill gaps in global SRHR funding.
The Netherlands, too, has taken on a significant leadership role in the family planning subsector. Even before the US implemented the global gag rule, the Netherlands had started to scale up its funding for family planning, tripling spending between 2015 and 2016 to a total of US$21 million, ultimately reaching US$30 million in 2019. With the US abdicating its role as a global leader in the family planning space, the Netherlands decided to take a bold policy and financing stance on the issue, launching the ‘She Decides’ campaign and embedding SRHR frameworks at the highest levels of its development policies.
For further analyses of funding for family planning, recommended readings include:
1 Modern contraceptive methods are defined here as any of the following: permanent (female and male sterilization); long-acting reversible methods (implants and IUDs); short-acting methods (hormonal pills, injectables, male and female condoms, emergency contraceptive pills, patches, rings, diaphragms, vaginal spermicides and other supply methods); lactational amenorrhea method, which involves exclusive breast-feeding for up to six months postpartum; two fertility awareness-based methods: standard days method and two day method. Traditional methods, which are not considered modern contraceptive methods in this Insight, include periodic abstinence, withdrawal, abstinence, and breast-feeding. This definition is based on a 2019 report from the Guttmacher Institute, ‘Adding it Up: Investing in Sexual and Reproductive Health 2019’._
2 UNAIDS’ ‘sub-Saharan Africa’ designation includes Angola, Benin, Botswana, Burkina Faso, Burundi, Cameroon, Cape Verde, Central African Republic, Chad, Comoros, Congo, Côte d'Ivoire, Democratic Republic of the Congo, Equatorial Guinea, Eritrea, Eswatini, Ethiopia, Gabon, Gambia, Ghana, Guinea, Guinea-Bissau, Kenya, Lesotho, Liberia, Madagascar, Malawi, Mali, Mauritania, Mauritius, Mozambique, Namibia, Niger, Nigeria, Rwanda, Sao Tome and Principe, Senegal, Seychelles, Sierra Leone, South Africa, South, Sudan, Togo, Uganda, Tanzania, Zambia, and Zimbabwe.
3 The funding figures quoted in this report may differ slightly from that of PNCH due to changes in the US$ conversion rate. In this report, spending is quoted in US$ according to 2019 prices.
4 Figure 3 appears to show dramatic peaks and valleys in US spending for SRHR; this is due to several combined factors, primarily irregular timing in disbursements, such that spending in some years appears to look twice as low or twice as high as appropriations actually were. In some cases, allocations to the SRHR subsectors did take significant cuts: for example, STD control in 2015. Because STD control is by far the largest area of US SRHR spending, these cuts pulled the whole curve down, despite the fact that spending in the other two subsectors remained steady or increased. A granular analysis of funding trends to the individual purpose codes is given later in the piece.
5 It is worth noting, however, that because the OECD purpose codes do not directly align with the budget lines in the US’ development budget, OECD data on US ODA for reproductive health care is not reflective of the US government’s understanding of their own SRHR funding priorities. For example, US funding for projects targeting maternal, newborn, and child health (MNCH), considered its own funding line in US budget documents, is grouped together under the umbrella of ‘reproductive health’ when it is reported to the OECD. Because MNCH funding is a US development priority, it represents a significant portion of US funding marked with this purpose code.
6 US Congressional appropriations provided on a yearly basis but may be disbursed over a multiyear period. The fluctuations in disbursements that the OECD data appears to show are attributable to a variety of factors including the timing of disbursements or the realignment of programs; they are not necessarily reflective of political commitments. Congressional appropriations to most U.S. programs were relatively flat during the decade between 2009 and 2019. The reproductive health purpose code now captures maternal, newborn, and child health (MNCH) funding, but until changes were made under the Obama administration, it was recorded under the basic health purpose code. The code for some (but not all) of the MNCH funding was later reallocated to the reproductive health code, resulting in further fluctuations in the US disbursements depicted in Figure 5.
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