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Methodology

CHANGE worked with the Global Women’s Institute (GWI) at the George Washington University to develop the SRHR Index’s methodology. The SRHR Index uses standardized indicators and globally recognized standards in SRHR to assess government policies, investments, and programs to produce a composite grade of the way U.S. global health assistance is, or is not, promoting SRHR globally.

The indicators reflect three significant domains of SRHR: FP, MCH, and HIV and AIDS. Each domain has policy-related indicators and budget-related indicators for each actor — the grades for all indicators are combined and weighted to generate a composite grade. A second transparency grade is then calculated and applied to this composite grade, based on the availability and accessibility of data.

Policy Scoring

Each SRHR-related policy and legislation is graded on whether the action is deemed to have hindered or promoted SRHR. Grading follows a nine-point scale (1 through 9), with 1=substantially hindered; 5=having little effect; and 9=substantially promoted. A grade is determined considering how evidenced-based, consistent with human rights norms and principles, responsive to need, and gender transformative that action was in regard to SRHR. Policies or legislation that affect all SRHR domains are considered across all three domains, whereas actions that only affect one domain are only considered in that domain’s grade.

Cross-cutting themes are used to evaluate laws and policies. For example, GBV is not included as a standalone domain, as it is not necessarily distinct in U.S. government budgets and reports (i.e., there is no GBV line item in the USAID budget). By including GBV, data collectors and graders would receive little information to quantify and it would present a challenge for rigorous application of the SRHR Index on an annual basis. GBV is included as a cross-cutting theme used to evaluate laws and policies, namely whether those laws and policies are gender transformative. The other cross-cutting themes are whether and to what extent laws and policies are responsive to need, evidenced-based, and consistent with internationally recognized human rights principles.

Grades are based on both the quantity and the quality of global health assistance SRHR-related activities. Quantity is graded primarily in terms of the amount of funding directed toward SRHR activities each year. Quality is graded on the extent to which the SRHR activities supported by that funding are evidence-based, responsive to need, consistent with internationally recognized human rights principles, and gender transformative.

Some policy actions that take place in a year may not fit squarely into any of the three domains (FP, MCH, and HIV and AIDS), but rather are broadly SRHR-related. These actions are graded using the same criteria as any other domain-specific policy action and are included in each domain.

SRHR Index grades are given on the calendar year. Graded budget requests are for the subsequent fiscal year, which runs from October 1 to September 30 for the U.S. government.

Gender Transformative

Programs and policies that address FP, MCH, and HIV and AIDS should be gender transformative, meaning they foster critical examination of gender norms and dynamics, strengthen or create systems that support gender equality, strengthen or create equitable gender norms and dynamics, and change inequitable gender norms and dynamics. When grading a policy, the SRHR Index considers whether the policy is gender blind, gender exploitative, gender accommodating, or gender transformative.

The SRHR Index uses the following definitions:

Gender blind policies and programs ignore the set of economic/social/political roles, rights, entitlements, responsibilities, and obligations associated with being male/female. They further ignore the power dynamics between and among genders. Gender exploitative programs and policies reinforce or take advantage of gender inequalities and stereotypes. Gender accommodating programs and policies work around existing gender differences and inequalities.1

Transparency

The U.S. government should support SRHR through its global health assistance, but it is also important that the information required to gauge and assess this support is readily available, accessible, and informative. For this reason, the SRHR Index includes a separate, analogous, transparency scale that calculates each criterion based on the availability of its source data.

Transparency is rated on a four-point scale (1=lowest and 4=highest). This transparency grade is then merged with the SRHR grade to generate a final grade by domain and actor. This final grade reflects the quality of government action (or inaction) with regard to SRHR and the availability of data with which to make this assessment. A ‘bad grade’ can be interpreted as being reflective of bad policies or insufficient budget allocations. In addition, an actor can receive a ‘bad grade’ due to insufficient or inadequate data. A ‘good grade’ only reflects good policies/budget allocations since the SRHR Index does not reward the government for transparency and availability of information.

As the creators of the SRHR Index, CHANGE recognizes that lack of available data or insufficient data is not necessarily a reflection of wrongdoing or lack of political will on the part of the government. The U.S. federal government is expansive, and the amount of data spread across the various entities and agencies is unwieldy. However, the benchmark to which to hold one’s government accountable should remain available and accessible information.

Determining the Domains

The SRHR Index examines FP, MCH, and HIV and AIDS. These domains were selected to mirror the silos in which the U.S. government structures its global SRHR programming and funding streams. The selected domains should not be interpreted as “what is important” in global SRHR, but rather “what is funded” in the U.S. government’s SRHR global health assistance.

Determining the Actors

Because the SRHR Index is intended as a transparency and accountability tool to grade Congress and the administration, both the White House and Congress were assessed in each of the domains, as well as federal agencies with significant or impactful work in SRHR. This determination varied by domain and was based on which agencies were responsible for programming and received funding for global SRHR activities within the relevant domains. Consultations with experts in the field, government sources, and Kaiser Family Foundation (KFF) fact sheets further informed this decision.

Criteria for Grading

White House

Executive Orders and Presidential Memoranda

The primary data sources used to asses the White House’s policy-related activities in each domain are Executive Orders (EOs) and Presidential Memoranda. EOs and memoranda are assessed as an expression of the White House’s influence and direction related to the establishment of policies and procedures guiding U.S. global health assistance and policy activities related to SRHR.

Public statements issued by, or made on behalf of, the White House were ultimately not used because public statements can be made via many channels and remain difficult to accurately and uniformly track.

Legislation signed or vetoed

The data source used to assess the White House’s policy-related activities in each domain is legislation signed or vetoed by the president in the target year. Signing or vetoing bills is an overt statement of the White House’s support for or opposition to legislation related to global SRHR.

President’s budget requests

The president’s proposed budget for the next fiscal year is the data source used to assess the White House’s budget-related activities in each domain. The president’s budget request is included as an expression of the White House’s direction and support or opposition related to encouraging funding for U.S. global health assistance related to SRHR.

Family planning

The two budget lines from the president’s budget request used to evaluate the White House on how it promoted or hindered family planning through its global health assistance are: 1) family planning funding proposed for USAID and 2) contributions to UNFPA, which are managed through the State Department. These budget lines were selected because they are the two primary mechanisms by which U.S. global health assistance is used to promote family planning internationally. To grade the White House on this criterion, these two budget lines are added together and divided by $8 million. The result will be a grade between 0-100. Eight million dollars was selected as an appropriate dividend after considering both what other countries of similar gross national product (GDP) contribute to international family planning (e.g. Australia, Canada, Denmark, France, Germany, Netherlands, Norway, Sweden, the United Kingdom) as well as the InterAction Coalition recommendations for international family planning funds.

Maternal and child health

The three budget lines from the president’s budget request used to evaluate the White House on how it promoted or hindered maternal and child health through its global health assistance are: 1) contributions to UNICEF; 2) contributions to UNIFEM (now known as UN Women); and 3) maternal and child health funding proposed for USAID. These three budget lines were selected because they are the three primary mechanisms by which U.S. global health foreign assistance is used to promote maternal and child health internationally. Money allotted to the Centers for Disease Control and Prevention (CDC) for immunizations is not included, though Gavi, the Vaccine Alliance is included, as it comes with USAID’s maternal and child health budget. To grade the White House on this criterion, these three budget lines will be added together and divided by $11 million. The result will be a grade between 0-100. Eleven million dollars was selected as an appropriate dividend after considering both what other countries of similar GDP contribute to international maternal and child health as well as the InterAction Coalition recommendations for international maternal and child health funds.

HIV and AIDS

The significant U.S. government investments in PEPFAR and the Global Fund make HIV and AIDS the domain in which the most money is spent. These two budget lines were selected because they are the two primary mechanisms by which U.S. global health assistance supports the HIV and AIDS response internationally. To grade the White House on this criterion, these two budget lines are added together and divided by $50 million. The result is a grade between 0-100. Fifty million dollars was selected as an appropriate dividend after considering both what other countries of similar GDP contribute to the international HIV and AIDS response as well as the InterAction Coalition recommendations for international HIV and AIDS funds

Congress

Legislation passed or repealed

The data source used to assess Congress’s policy-related activities in each domain is legislation Congress passed, maintained, or repealed in the target year. Given the frequency with which continuing resolution bills are amended, stand-alone legislation and any relevant amendments that were added to continuing resolutions are included. Enacting or repealing bills is an expression of Congress’s direction, management, and guidelines related to the delivery of SRHR services in U.S. global health assistance, as well as an expression of Congress’ support for, or opposition to, global SRHR.

Congress’s budget appropriations

Congress’s budget appropriation in the target year for the next fiscal year is the data set used to assess its budget-related activities in each domain. Congress’s budget appropriation is included as an overt statement of its priorities and specifically its support for, or opposition to, global SRHR in U.S. global health assistance.

Family planning

The two budget lines from annual Congressional appropriations used to evaluate Congress on how it promoted or hindered family planning through its global health assistance are: 1) family planning funding proposed for USAID and 2) contributions to UNFPA, which are managed through the State Department. These budget lines were selected because they are the two primary mechanisms by which U.S. global health assistance is used to promote family planning internationally. To grade Congress on this criterion, these two budget lines are added together and divided by $8 million. The result is a grade between 0-100. Eight million dollars was selected as an appropriate dividend after considering what other countries of similar GDP contribute to international family planning, as well as the InterAction Coalition recommendations for international family planning funds.

Maternal and Child Health

The three budget lines from annual Congressional appropriations used to evaluate Congress on how it promoted or hindered maternal and child health through its global health assistance are: 1) contributions to UNICEF; 2) contributions to UNIFEM (now known as UN Women); and 3) maternal and child health funding proposed for USAID. These three budget lines were selected because they are three primary mechanisms by which U.S. global health assistance is used to promote maternal and child health internationally. Money allotted to the CDC for immunizations is not included, though Gavi is included here as it comes out of USAID’s maternal and child health budget. To grade Congress on this criterion, these three budget lines are added together and divided by $11 million. The result is a grade between 0-100. Eleven million dollars was selected as an appropriate dividend after considering what other countries of similar GDP contribute to international maternal and child health, as well as the InterAction Coalition recommendations for international maternal and child health funds.

HIV and AIDS

The two budget lines from annual Congressional appropriations used to evaluate Congress on how it promoted or hindered HIV and AIDS response through its global health assistance are: 1) recommended funding for the Global Fund to Fight AIDS, Tuberculosis, and Malaria and 2) recommended funding for PEPFAR. These two budget lines were selected because they are by far the two primary mechanisms by which U.S. global health assistance supports the HIV and AIDS response internationally. The significant investments in PEPFAR and the Global Fund make HIV and AIDS the domain in which most money is spent. To grade Congress on this criterion, these two budget lines are added together and divided by $50 million. The result is a grade between 0-100. Fifty million dollars was selected as an appropriate dividend after considering what other countries of similar GDP contribute to international HIV and AIDS response, as well as the InterAction Coalition recommendations for international HIV and AIDS funds.

Agencies

Agencies’ internal policies and procedures

Agencies’ internal policies and procedures related to, or in any way affecting, global SRHR programming are the data source used to assess agencies’ policy-related activities in each domain. Agencies’ internal policies and procedures are included as an expression of the agencies’ direction, management, and guidelines related to the delivery of global SRHR programming, as well as an expression of agencies’ support for, or opposition to, global SRHR.

Agencies’ use of funds

How agencies use the funds allocated to them is the data source used to assess agencies’ policy-related activities in each domain. How well agencies spend the money allocated to them within each domain is included to assess the quality of the programming and interventions implemented by agencies against global SRHR standards and best practices.

Funding spent

The extent to which agencies spend the funding appropriated to them for global SRHR is the data source used to assess agencies’ budget-related activities in each domain. The extent to which agencies spend the funding appropriated to them for global SRHR is included as an expression of agencies’ commitment to delivering SRHR programming globally. A note that when the State Department is evaluated on this criterion in the Family Planning domain, the money evaluated is U.S. contributions to UNFPA only. Other family planning funds appropriated to the State Department are given to USAID for the implementation of family planning programs, and measured in that agency grade. In addition, when USAID is evaluated on this criterion in the HIV and AIDS domain, the money evaluated comes from the State Department. Given that the Global AIDS Coordinator (S/GAC) sits in the State Department, any funding USAID uses to implement HIV and AIDS programming comes from the State Department.

Agencies’ expenditure of funds

Expenditure of funds in countries with the highest fertility rate, maternal mortality rate, or incidence of HIV and AIDS is the data source used to assess agencies’ budget-related activities in each domain. Agencies’ expenditure of funds in countries with the highest fertility rate, maternal mortality rate, or incidence of HIV and AIDS is included as an expression of their commitment to delivering global SRHR programming that is responsive to need and maximizes positive impact on SRHR globally.

Family planning

This criterion looks at the extent to which agencies spent its funds in countries where it is needed most in family planning, which is determined based on where the highest total fertility rates are. The World Health Organization (WHO) defines total fertility rate as the total number of children born, or likely to be born, to a woman in her lifetime if she were subject to the prevailing rate of age-specific fertility in the population.

Grading is done by determining the countries with the highest total fertility rate that year (or for the most recent year with available total fertility rate data). Those with the highest total fertility rate are typically those countries above the global average total fertility rate. Graders then determines what percentage of international family planning money was spent by the United States per female capita in the countries with the highest total fertility rate.

Maternal and child health

This criterion looks at the extent to which agencies spent its funds in countries where it is needed most in maternal and child health, which is determined based on where highest rates of maternal mortality are. Complications during pregnancy and childbirth are a leading cause of death and disability among women of reproductive age in developing countries. The maternal mortality ratio represents the risk associated with each pregnancy.

Grading is done by determining the countries with the highest maternal mortality rate that year (or for the most recent year with available maternal mortality data). Those with the highest maternal mortality rate are typically those countries with rates higher than the global average maternal mortality rate. Two hundred and fifty per 100,000 and above was used as the cut-off to determine countries with the highest maternal mortality rate. Graders then will determine what percentage of international maternal and child health money the U.S. spent per female capita in the countries with the highest maternal mortality rate.

HIV and AIDS

This criterion looks at the extent to which an agency has spent its funds in countries where it is needed most in the HIV and AIDS response, identifying countries with the highest rates of incidence of HIV. ‘Prevalence’ of HIV was not selected as an indicator because data collection methods were not deemed to be as comparable and uniform as incidence data.

Grading is done by determining the countries with the highest incidence of HIV for people ages 15-49 that year (or for the most recent year with available data on incidence of HIV for people ages 15-49). Incidence data was only consistently available for this age range, which is a limitation of the methodology. Those with the highest HIV incidence are typically those countries above the global average HIV incidence, though graders can choose a cut-off around the average where there is a natural break (for example, in 2016 the global average HIV incidence was about .12, and .12 and above was used as the cut-off to determine countries with the highest HIV incidence rate).

Main Data Sources

Qualitative and quantitative data were collected for the SRHR Index, and came from a range of primary and secondary sources, including: InterAction, the Kaiser Family Foundation (KFF), Foreign Aid Explorer, ForeignAssistance.gov, Congress.gov, the Office of Management and Budget (OMB) website, Congressional Budget Justifications, WhiteHouse.gov and other government sources, such as reports, official policy documents and other documents related to agency priorities, guidelines, and procedures.

Kaiser Family Foundation

The KFF website is a key source for budget-related data, particularly the foundation’s “Breaking Down the U.S. Global Health Budget by Program Area” fact sheets for presidential budgets and Congressional appropriations. KFF is a respected non-partisan organization that collects information about the global health budget annually in a transparent, user-friendly, and dependable manner. This same information may be pulled directly from the presidential budgets and relevant Congressional appropriation bills, but are only referred to in the event the same information is not otherwise available in KFF’s fact sheets.

InterAction Coalition

InterAction Coalition’s annual budget recommendation is used to assess budget-related activities as the grading mechanism to evaluate the White House’s budget requests and Congress’s budget appropriations. As a coalition of respected aid organizations, InterAction is an appropriate standard bearer in matters related to U.S. global health assistance. Similarly, InterAction’s budget recommendations for each of the SRHR Index domains are appropriate benchmarks for budget expectations related to U.S. government’s funding for global SRHR. The InterAction site has also been used as a secondary source for Congressional appropriation numbers by SRHR domain on an annual basis.

World Bank

The World Bank provides data for criteria on responsiveness to need (total fertility rate, maternal mortality rate, incidence of HIV) and is a globally respected source for data. For constancy and transparency, it is good practice for the U.S. government to use statistics provided by the World Bank when determining where there is the greatest need for its global SRHR programming.

1 Interagency Gender Working Group (IGWG), Gender Integration Continuum Categories, available at www.igwg.org. Download Gender Integration Continuum Categories (PDF).