7

Foundation and Agency Programs and Priorities

Sunita Kishor (ICF) served as moderator for this session, which focused on the work and priorities of agencies and foundations that fund work in this area.

WILLIAM AND FLORA HEWLETT FOUNDATION

Althea Anderson serves as a Program Officer for the William and Flora Hewlett Foundation’s Global Development and Population Program, where she manages research and advocacy grant making for international reproductive health and women’s economic empowerment. Anderson also represented the Foundation at the Workshop on Reproductive Health and Global Development in May 2020. Anderson shared several links to resources describing the foundation’s evolving grant-making strategies.¹

The Hewlett Foundation refreshes its grant-making strategies approximately every five years. Refreshes are designed to evaluate current strategies, characterize progress, assess the evolution of the field over the previous five years, and shape the strategy for the next 5 years to create possible synergies across the Global Development and Population Program. An evaluation and refresh of the foundation’s international reproductive health (IRH) and women’s economic empowerment strategies was launched in March 2020. The evaluation found that the Hewlett Foundation’s reputation and contribution to sexual reproductive health and rights (SRHR) progress has been largely defined by its sub-strategies in francophone west Africa

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¹ See Hewlett Foundation at http://hewlett.org.

and its approach to local advocacy field-building in west and east Africa. Grantees agree that the Hewlett Foundation has made a marked difference in francophone west Africa by contributing to doubling voluntary contraceptive use in the nine Ouagadougou Partnership countries. Anderson said that Hewlett has also enabled several service delivery and advocacy organizations to expand operations in this sub-region. The Hewlett Foundation has seeded experimental approaches to improving service delivery and encouraging peer donors to scale these programs. For example, it has done work in human-centered design with IDEO.org and Marie Stopes International, which has expanded from Zambia to Kenya, the Sahel, and beyond.

Progress has been observed in Hewlett Foundation research initiatives that engage potential evidence users, leading to the eventual application of evidence for policy change and practice. The most promising cases engaged evidence users early in research design processes and aimed for applied and user-focused research with strong links to advocacy initiatives. Anderson highlighted the opportunity to further explore the role of research in supporting advocacy and service delivery.

The evaluation also found that the Hewlett Foundation is perceived by some stakeholders as more grounded in a women’s rights and reproductive rights framework compared to other reproductive health and family planning donors. Anderson hypothesized that this centralization of women’s aspirations and their relationships to reproductive health (as compared to a purely demographic approach to reproductive health) may be important for changing gender and social norms to support sustained changes in reproductive health outcomes.

Anderson shared findings from the Hewlett Foundation’s global and Africa regional landscape scans. SRHR remains critical for women, their families, and their communities because it supports and is associated with women’s and girls’ agency, health, educational attainment, and economic opportunity. The past decade has seen significant growth and use of SRHR services due to sustained focus and investments. Anderson said that continued support will expand current innovations—including community-based delivery, self-managed care, integration with other services, improvements to quality of care by addressing provider bias, and technology-enabled service delivery (e.g., telemedicine)—to further expand SRHR. New product innovation largely focuses on contraception, although Anderson noted that medication abortion is a major innovation that has expanded access to safe abortion around the world.

Anderson highlighted growing support to align reproductive health momentum with governments’ desire to capture a demographic dividend but reported that progress has been slow. Nonetheless, maintaining continued progress on SRHR may necessitate a strong enabling environment. Anderson explained the value of addressing demand-side factors, such as knowledge

and awareness building, while simultaneously shaping partner dynamics, engaging cultural influencers, and shifting gender and social norms.

Despite this progress, Anderson said, global opposition to reproductive health is rising and expanding from an anti-abortion focus to a broader opposition to gender equity and rights. All stakeholders acknowledged that more needs to be done to mitigate this opposition, including strengthening regional and in-country SRHR research and advocacy to address sensitive issues with government and other decision makers with greater credibility. The Maputo Protocol and other African regional commitments increasingly support gender equity and SRHR, and Anderson said this presents an opportunity for governments to push for related policies and investment.

Anderson suggested that research could focus on uptake of findings to inform advocacy, policy, and programming. She noted that the most effective research is often conducted in close partnership with ministries of health and finance, technical working groups, and key stakeholders, so that research is designed to address evidence users’ questions and is primed to shift policies and practices. This approach typically benefits from strong regional and in-country research capacity through sustainable institutions. Anderson also identified a gap in user research dedicated to better understanding what kinds of contraceptive access women want as well as what women’s broad aspirations and life goals are.

The Hewlett Foundation has reviewed these findings over the weeks leading up to the workshop and is beginning the next phase of the IRH strategy refresh. Anderson shared some areas of inquiry for future grant-making and framing. First, the foundation is considering broadening its strategic goal to deliberately position reproductive health within the broader context of women’s lives, well-being, and aspirations. To that end, Anderson asked workshop participants how the foundation should think about positioning its work in this broader context, and inquired how other donors have adopted a rights-based women’s empowerment grant-making approach and balanced it with the more traditional framing around family planning that remains prevalent globally. The second area of inquiry is increasing reproductive health demand. The Hewlett Foundation IRH strategy will continue to focus on expanding access to contraception and safe abortion, but also seeks to contribute to demand generation by considering the foundation’s role in reaching new contraceptive users. Anderson said that the Hewlett Foundation can play a leading role in expanding access to safe abortion with the introduction of medication abortion and is investigating ways to capitalize on this opportunity.

The Hewlett Foundation also wants to strengthen the enabling environment for SRHR. Anderson recognized that multiple influencers, including intimate partners, families, communities, and societies, can support girls’ and women’s agency and well-being, including access to reproductive health

care. Thus, the Hewlett Foundation is exploring ways to leverage its investments for impact at these various scales in order to contribute to an enabling environment in which women can achieve their aspirations through reproductive agency. In addition, the foundation strives to continue to bridge the gap between knowledge production and evidence use and seeks opportunities at regional and national levels. New investments will aim to ensure that evidence users are integrated throughout the research process to meaningfully inform policy and practice.

Anderson said that the Hewlett Foundation is exploring synergies between the IRH and women’s economic empowerment strategies to expand current investments, including linkages between women’s reproductive choices and their economic agency. In the women’s economic empowerment strategy refresh, the Hewlett Foundation will explore new investments to ensure the availability of accurate data and a sound empirical base of evidence on women’s unpaid work to inform more gender-aware macroeconomic and social benefit policies. The foundation has learned that researchers have struggled to meaningfully engage advocates, practitioners, and policymakers to value and use evidence on women’s unpaid work. Integrative analyses on women’s unpaid work and reproductive choices are limited, so this intersection is not often considered in national policies.

The Hewlett Foundation is also exploring its role in reimagining global development. Anderson said that the field, including SRHR, is undergoing a necessary period of reckoning with a focus on shifts of power, influence, and decision-making from global to national to regional actors. The foundation is considering its role in this process given its niche and values and will finalize and disseminate its new strategy in the second and third quarters of 2021.

In the discussion, Megan O’Donnell expressed an interest in strengthening linkages between evidence generation and use through communication between researchers and evidence users, and she asked how the Hewlett Foundation and other donors may encourage that communication. Anderson responded that the Hewlett Foundation has required nearly all of its grantee partners for IRH and women’s economic empowerment research investments to include a robust research uptake plan that clearly outlines which evidence users will be engaged and how they will be engaged throughout the research process. The foundation also asks researchers which regional and national policymakers, decision-makers, and advocates have shown a demonstrated interest in that evidence. Tamara Kreinin added that the Packard Foundation partners global researchers with local researchers, in part to provide mentorship to local researchers with less of a global presence and also to bring global researchers closer to evidence users and policymakers; in that way, she said, Packard Foundation funding is “practical research for advocacy.”

Nancy Birdsall asked how U.S.-based donors are reacting to the risk of a continuing decline of reproductive rights in the United States. Anderson responded that USAID’s global development team—and particularly the women’s choices pillar—has done some scenario planning to determine what the possible impacts of the 2020 election may mean for USAID investments. Anderson noted that some policy advocacy investments have shifted to work on changing cultural narratives in the United States, specifically in the American South.

UNITED NATIONS POPULATION FUND

Benoit Kalasa presented an overview of five programming priorities for the United Nations Population Fund (UNFPA). UNFPA’s strategic plan is framed within a Decade of Action that sets a 10-year horizon for achieving its SDGs by 2030. When UNFPA adopted the SDGs, it urged the world to consider the life of a 10-year-old girl and what she would need to fulfill her potential. This motivational framework is intended to prompt nations to consider the health and well-being of young girls as their national economies grow. The principle of leaving no one behind and reaching those furthest behind first permeates the strategic plan. To uphold this principle, UNFPA believes that it must meet the needs of the estimated 270 million women who want to avoid pregnancy but are not using safe and effective family planning methods. Kalasa said that UNFPA has focused on three transformative goals: ending the unmet need for family planning, ending preventable maternal mortality, and ending harmful practices, such as gender-based violence. Kalasa noted that UNFPA is also interested in observing the intersection among these three goals.

UNFPA’s SDG Target 5.6 is to ensure universal access to SRHR. This target includes two indicators. Target 5.6.1 centers on the proportion of women ages 15-49 who make their own informed decisions regarding sexual relations, contraceptive use, and reproductive health care. Target 5.6.2 focuses on the number of countries with laws and regulations that guarantee full and equal access of women and men ages 15 and older to SRH care, information, and education. Kalasa said that research on both of these indicators has revealed major challenges and helped UNFPA identify where greater effort is needed. For example, 97 out of 107 countries surveyed have laws and regulations that guarantee access to contraceptive services; however, 28 percent of these countries have minimum age requirements to access contraceptive services, and 21 percent have restrictions based on third-party authorization. Data monitoring is key to inform future work to advance the rights and choices of women.

UNFPA is also working in the area of demographic dividends. This effort seeks to ensure that young people realize their rights to decide

whether and when to have children and to achieve the related promise of economic growth. The Sahel Women’s Empowerment and Demographic Dividend (SWEDD) collaborative program with the World Bank was implemented in six countries in west Africa to examine how adolescent girls’ and adult women’s economic autonomy and education enable them to access information and services related to SRHR. The program is expanding into another 3 countries, and through the Human Capital Plan will eventually reach up to 25 countries. Kalasa said this expansion was important to determine how countries can leverage their domestic resources to support SRHR and that the UNFPA is building more partnerships and synergies.

Through the UNFPA Supplies Program, contraceptives are procured and distributed to 46 priority countries. This program benefits from many donors and key partnerships, including the Bill & Melinda Gates Foundation. Kalasa said that UNFPA is working on a new vision for this program, which will assess the learnings from the past decade in order to meet the goal of ending unmet family planning needs and preventable maternal mortality by increasing equitable access to high-quality modern contraceptives and life-saving maternal health. The SRHR of women are at the center of this program, which is built around a compact of accountability and leadership across government, civil society, the private sector, and the United Nations.

Rebuilding after the COVID-19 pandemic is the final program priority Kalasa presented. At UNFPA, the response to COVID-19 has focused on preserving momentum on three strategic priorities: supporting continuity of SRH services, addressing gender-based violence, and maintaining the supply of modern contraceptives and reproductive health commodities. Kalasa said that UNFPA is working with governments and key partners on a concerted effort to mitigate the impact of the pandemic by ensuring that SRHR services are considered essential services during COVID-19 response—for example, through availability of personal protective equipment (PPE) for health and family planning providers, supply-chain preservation for reproductive health products, and continuation of rights-based family planning services that offer a range of contraceptive services.

As UNFPA enters the Decade of Action to achieve the SDGs, it is fully committed to continuing to support countries and uphold the rights of individuals—especially women—to plan their families. UNFPA is striving to end all unmet need for voluntary family planning by 2030, and Kalasa reiterated the need for continued collaboration and research to achieve this goal.

Sunita Kishor asked how UNFPA can ensure that governments do indeed work within the women’s rights framework. Kalasa replied that human rights are a basic principle for United Nations work and that UNFPA representatives’ core focus is to monitor and advance SRHR. UNFPA also seeks to engage women and youth organizations in that advocacy.

DAVID AND LUCILE PACKARD FOUNDATION

Tamara Kreinin said that the David and Lucile Packard Foundation works on a continuum of reproductive health rights and justice. The Packard family and foundation team articulate a set of core values that drive their approach to these issues, including investment in strong leadership, integrity, and a sense of equity and justice. The foundation’s programs focus heavily on context, with all funded locations having local advisors and, in the case of Addis Ababa, a full office. These local advisors inform the foundation of national and regional needs and changes. They also perform “beyond the check” work, holding conferences and meeting with governments, funders, and civil societies within the local context, which elevates the foundation’s initiatives. Efforts are evidence-based and increasingly performed through a justice and equity lens.

The Packard Foundation has operated within the framework of a consistent strategy for the past eight years and will present a new strategy in 2022. Partners and experts in the field will help to evaluate the foundation’s work and provide context, information, and evidence to inform the new strategy. A new president was instated on August 31, 2020, and Kreinin noted a generational shift on the board. During the past six months, following the COVID-19 pandemic and murders of Black men and women in the United States, the Packard Foundation board has called for an even more focused evaluation of how the foundation’s work interacts with this justice lens.

The Packard Foundation tends to fund services, policy, advocacy, organizing, shifting of social norms and communication, and research. The Foundation operates in sub-Saharan Africa (Ethiopia, Rwanda, Kinshasa DRC), south Asia (India, Myanmar), and the United States (primarily Louisiana and Mississippi). Kreinin noted that work in all regions is mutually informative. The foundation’s work includes a range of SRHR and justice initiatives. This range begins with sexuality education through a gendered lens and a trauma-informed emphasis on resilience. This approach is based on research that indicates the inclusion of gender, trauma, and resilience in sexuality education increases its impact. Kreinin highlighted the goal of providing youth-friendly services and ending child marriage with this generation. Contraception and family planning are also part of the foundation’s work, and Kreinin recognized the need for a focus on both concepts separately, given that most young people do not want to plan a family but do want contraception. The Packard Foundation considers abortion to be a part of contraceptive services in an ideal world.

The Packard Foundation’s work is aligned according to two primary threads. The first thread of work is related to quality, which Kreinin said is centered on rights and includes good counseling, the ability to switch contraceptive methods without question, a lack of provider bias,

and contraceptive availability and choice. The Foundation is following a patient-centered approach, which Kreinin noted is meant to be adapted to the specific geography of the recipient population. Kreinin acknowledged that women who do not experience quality are more likely to walk away from SRH services and health care services in general. The Packard Foundation also considers quality as it relates to stigma. Kreinin pointed out that although the foundation’s focus on stigma began with abortion-related stigma, it has now expanded to stigma related to all contraception, family planning, and sexuality education. The second thread of the foundation’s work focuses on young people, both as recipients of services and information and as leaders, activists, and movement builders.

Kreinin said that cross-issue mobilizing is increasingly the goal of young people and that the Packard Foundation is working to understand the impacts of that form of mobilization on reproductive health services and policies. Kreinin also commented on ongoing efforts to research and facilitate culture and norm shifts, for example by using the arts to stimulate conversations about abortion in Louisiana.

The Packard Foundation is cognizant of opposition to its efforts, which Kreinin recognized has surged recently around the globe. The foundation is also focused on humanitarian settings that are homes for internally displaced individuals and refugees. Kreinin said the foundation is working to increase sexuality education, delay early marriage, and ensure that women have access to contraceptive services and abortion in those contexts.

Universal access to health care is a priority for the Packard Foundation, with an emphasis on SRHR. This priority has expanded to encompass research on access to and quality of telemedicine, particularly in light of the COVID-19 pandemic. Kreinin acknowledged that marginalized women often do not have access to the technology or privacy needed to take advantage of telemedicine. The Packard Foundation has commissioned research on telemedicine in India to better understand meaningful delivery of telemedicine to vulnerable populations. The foundation is also committed to self-care and self-administered or over-the-counter contraceptive services, including medication abortions and contraceptives through delivery mechanisms such as Sayana Press. Kreinin recognized the potential for governments to claim that women do not need facilities or counseling because of the availability of self-administered solutions, and noted that the foundation seeks to provide women with choices and an ability to obtain information for themselves.

Kreinin concluded by reiterating that the Packard Foundation increasingly focuses on justice and equity, particularly as they intersect with funded outcomes related to family planning, abortion, and sexuality education.

In the discussion, Ann Blanc asked whether the Packard Foundation has considered how to practically aim for improvements in both reproductive

health outcomes and justice and equity, for example by determining important indicators of justice and equity. Kreinin responded that the foundation is shifting funding to address this issue: first, through a focus on ensuring that the most vulnerable and marginalized individuals receive high-quality services and care, and second, through power-building movements that elevate the voices of those individuals. For example, when the foundation discovered that some of its work in India was not reaching the poorest communities, it intentionally shifted its work to reach those communities and further adapted the work to maintain quality in the new context. The Packard Foundation also funds reproductive justice groups in the American South and aims to add funding that will support dual outcomes related to equity and justice as well as reproductive health. Kreinin emphasized the importance of intersectional movement-building, predicated on the notion that (to paraphrase Audre Lorde) women do not lead single-issue lives.

Nancy Birdsall asked how U.S.-based donors are reacting to the risk of a continuing decline of reproductive rights in the United States. Kreinin said that the Packard Foundation has long funded both global and U.S. work and that the board increased U.S. funding efforts after the most recent change in administration. The foundation has also started a collaborative on gender and reproductive equity based on the premise that American SRHR advocates are undersupported, underfunded, and overwhelmed. To that end, the Packard Foundation has committed an extra $50 million over five years and has engaged other foundations as well as individual philanthropists to bring more funds into the field. In addition, the foundation has an increased interest in the American South, where the region’s health disparities (particularly in Louisiana) intersect with the gender, equity, and justice lens that the foundation is increasingly using to guide its efforts. Kreinin added that the foundation’s global work is instructive for the U.S. context.

OFFICE OF POPULATION AND REPRODUCTIVE HEALTH, USAID

Afeefa Abdur-Rahman is an institutional contractor who serves as a senior gender advisor in the Office of Population and Reproductive Health (PRH) in the Global Health Bureau at USAID. USAID maintains that investing in women’s economic empowerment builds countries that are resilient and self-reliant, because an investment in a woman is an investment in her community and her country. The Women’s Economic Empowerment Act of 2018 requires gender analyses to shape USAID strategies and projects in all sectors. USAID’s family planning programs support the right of individuals and couples to make and act on decisions about whether and when to have children. Thus, the principles of voluntarism and informed choice are central to the USAID vision and mission. Abdur-Rahman said

that USAID investments strengthen countries’ capacities to provide family planning information, services, and modern methods as well as create enabling environments, including more gender-equitable norms that will allow people to achieve their reproductive intentions. Abdur-Rahman pointed out that abortion is not a part of USAID family planning programming.

Abdur-Rahman said that voluntary family planning programs that expand choice, promote dialogue, and empower clients to make decisions that meet their individual needs contribute to their overall empowerment. Abdur-Rahman further recognized that expanding women’s access to contraception improves women’s health and creates opportunities beyond childbearing, including the ability to access education and participate fully in the workforce. Family planning also helps women time and space pregnancies to ensure healthy outcomes for themselves and their children. At the societal and national levels, voluntary family planning contributes to economic growth and population resource balance.

To make and act on voluntary, informed family planning decisions, Abdur-Rahman said individuals must have access to accurate family planning information, be able to choose whether to use contraceptives, and have access to a range of contraceptive methods and services. The goal of PRH’s empowerment work is to engage with individuals, families, communities, and health systems to improve both gender equality outcomes and to help women, men, and couples achieve their reproductive intentions. Abdur-Rahman said that an empowered individual or couple that voluntarily uses contraception that matches their current intentions at that particular time is at the center of that goal.

Given the role of gender norms, power dynamics, and inequalities in how individuals navigate reproduction and contraception use, PRH has prioritized three technical areas to improve gender dynamics across the life course and enhance family planning outcomes: reproductive empowerment (i.e., informed choice, voice, and power to act on fertility desires without fear of violence), male engagement (i.e., men as users, supportive partners, and agents of change in a way that centralizes gender and power dynamics), and gender-based violence (GBV) mitigation (i.e., prevention of and response to GBV in the family planning context).

Abdur-Rahman explained that PRH interventions within these three priorities promote and increase women’s empowerment in myriad ways that overlap with and reinforce each other. Interventions address women’s power within (e.g., women’s knowledge of family planning; self-awareness and self-worth; expectation of a supportive partner, healthy relationships, and quality health care), power to (e.g., ability to voice intentions to partners and agency to engage in decision-making and strengthened supportive environments where male partners are empowered to nurture women’s agency), and power with (e.g., collective action to achieve

fertility desires and advocacy for improved access to family planning care). Abdur-Rahman highlighted another dimension—power over (i.e., addressing threats to women’s agency)—as a cross-cutting element under PRH’s three gender priorities.

Outcomes of PRH’s family planning and empowerment work will manifest at multiple levels. At the individual level, outcomes include but are not limited to access to resources, agency, attitudes toward family planning and family planning methods, self-efficacy, body literacy, and fertility behavior. At the relationship level, outcomes can address couple dynamics and relationship quality, communication, and decision making. At the community level, programs can measure shifts in gender norms and changes in collective actions to hold leaders and health systems accountable. At the systems level, interventions are geared toward outcomes related to provider competency to offer respectful, non-judgmental, and gender-sensitive services; gender norms; gender-transformative support supervision; and reduction of discrimination and harassment in the workforce. At the policy level, work can measure the extent to which health policies and budgets are gender-responsive with the goal of empowerment of women, men, and couples.

Abdur-Rahman highlighted several illustrative approaches that PRH has supported that contribute to empowerment, engage men, and mitigate gender-based violence. One such intervention in Kenya, Addressing Reproductive Coercion in Health Settings (ARCHES), was a pilot clinic-based model that enabled providers to identify reproductive coercion and intimate partner violence among women seeking family planning counseling, as well as provide targeted voluntary family planning counseling and referrals for follow-up support. A second intervention supported the development and testing of two digital health tools: Smart Couple and Smart Client. These tools used prerecorded interactive voice response calls, SMS, and entertainment education to provide women and men with education that prepares them to access voluntary family planning services and encourages conversation about family planning. In Uganda, a third initiative supported the Gender Roles, Equality and Transformation (GREAT) Project, a community-based intervention that addressed the link between unequal gender norms and reproductive health in married and unmarried youth. The GREAT Project improved gender-equitable attitudes, family planning use, and male engagement in child care and household chores. In east Africa, a fourth effort has supported methodologies that strengthen leadership, advocacy, and accountability skills of women leaders and helped those women to foster joint accountability for family planning within health systems. In a fifth example, PRH invested in developing a framework and training modality that offers a set of competencies for providers to offer gender-equitable service provision that empowers clients.

PRH aims to harmonize its empowerment principles with new voluntary family planning service delivery efforts that intersect with other health areas, including maternal and child health, nutrition, and health care, including in fragile settings. Moving forward, PRH will also continue to support development of measures of agency and empowerment and will use those measures in more projects and countries to refine measurement and understand how interventions influence agency and decision-making. Based on existing evidence and theory, PRH is also supporting the development of a theory of change for male engagement in family planning, including pathways to gender equality, agency, and empowerment and family planning outcomes for both women and men. Sunita Kishor added that USAID also funds the Demographic Health Surveys.

In the discussion, Megan O’Donnell expressed concern with the way that family planning is positioned within the USAID draft gender policy in its reference to family planning only in the context of marriage. Abdur-Rahman responded that interest in this updated policy has been tremendous and that USAID appreciates the attention and interest in ensuring the policy is as strong as possible. She added that USAID was in the process of reviewing comments on the updated policy (at the time of the workshop). The review process is being directed by Julie Cram (Senior Coordinator for Gender Equality and Women’s Empowerment) and Sarah Gesiriech (Special Advisor on Children in Adversity).

BILL & MELINDA GATES FOUNDATION

Ann Starrs shared that the family planning strategy at the Bill & Melinda Gates Foundation has undergone a year-long refresh that is slated for completion by early 2021. The Gates Foundation is committed to maintaining a funding level of $280 million per year for family planning. One significant change to the budget is a ramping up of investment in contraceptive technology research and development, which will comprise 30 percent of the budget moving forward.

The Gates Foundation family planning strategy is anchored in understanding women’s and young people’s preferences and priorities, which is critical to addressing their reproductive needs. Starrs clarified that although the Gates Foundation uses the term family planning, its strategy focuses on access to and use of contraception. The strategy is based on three broad elements of the Gates Foundation’s theory of change. The first element is the expansion of contraceptive method choice, which is the basis for the budget increase to promote contraceptive technology research and development. Starrs recognized that women’s concerns about contraceptive side effects are a major barrier to use and continued use of contraception. Technology is a key part of the foundation’s overall comparative advantage and focus,

and the goal of this research and development effort is to adapt existing and develop new contraceptive methods that will eliminate or reduce the side-effects barrier. Expansion of contraceptive method choices requires access to the range of contraceptive methods, and to that end the Gates Foundation will also study issues related to market shaping, launching, and the availability of new products and to supply chain issues as well to ensure access for women and young people.

The second element is to optimize family planning interventions on both the supply and demand side to address barriers that prevent women and young people from making and acting on decisions for their reproductive intentions. This effort revolves around providing knowledge about contraceptive methods and building supportive family, community, and broader contexts to facilitate decision-making. The Gates Foundation is also investigating the role of the private sector in expanding and maximizing access to appropriate contraception and is exploring the expansion of access to self-care methods, driven in part by the recent COVID-19 pandemic.

The third element of the theory of change maximizes access to high-impact interventions through and with scaling levels. This expansion of access involves work with a range of partners in the global family planning ecosystem to promote the adoption and scaling of high-impact family planning practices, both established and novel. These three strategic elements of the theory of change are supported by cross-cutting work on data and accountability as well as advocacy.

Starrs reported that the Gates Foundation brought its family planning, maternal/newborn child health, and nutrition teams into a cluster in 2019 (currently called FP/MNCH/nutrition). The three teams retain their independent budgets, workstreams, and strategies, but the clustering is intended to highlight opportunities for linkages and streamlining, such as in postpartum family planning. In January 2020, the Gates Foundation also established a new division on gender equality; its inaugural president, whose tenure will begin in November 2020, will develop the focus for that division. Starrs recognized the clear bidirectional linkages between the goals of the family planning strategy and gender equality. In addition, the foundation is having an ongoing conversation surrounding diversity, equity, and inclusion related to its own structures, policies, and internal culture, as well as implications for partnership and voice.

Starrs acknowledged that the Gates Foundation has a significant budget and said that its resources will be applied to what the foundation considers to be its comparative advantage and value-add. The key elements and priorities of the family planning strategy are shaped by this rationale. Starrs emphasized that elements left out of the strategy for this reason are neither inherently viewed as unimportant by the Gates Foundation nor will they be entirely excluded from the conceptual framework of the strategy.

Starrs also noted that historically, much of the Gates Foundation’s work has been driven out of Seattle. Moving forward, although Seattle will remain a central location, country-specific strategies in focus geographies—especially those that have a country office—will be more clearly anchored in those countries.