Methodology

Beginning in 2017, the Center for Health and Gender Equity (CHANGE) worked with the Global Women’s Institute (GWI) at the George Washington University to develop the Sexual and Reproductive Health and Rights (SRHR) Index methodology. Fòs Feminista carries forward the SRHR Index along with the work of CHANGE, the International Women’s Health Coalition (IWHC), and the International Planned Parenthood Federation Western Hemisphere Region (IPPFWHR).

The SRHR Index grades the U.S. government’s commitment, leadership, funding levels, and transparency across a comprehensive set of SRHR issues and ensures that this information is publicly available. The SRHR Index grades allow users to understand U.S. government actions not only within a particular domain of SRHR, but also across SRHR more broadly.

On an annual basis, the SRHR Index reviews, analyzes, and scores global health actions across key U.S. government agencies and funding streams related to SRHR using standardized indicators and globally recognized standards. This scoring process results in a set of grades at the domain, actor, and whole of government levels that reflect the level to which global health assistance did, or did not, promote SRHR globally that year. Actors graded by the SRHR Index receive a grade for each domain in which they work, as well as an overall grade. The U.S. government receives an overall grade for each domain as well as a cumulative grade that represents the level to which U.S. global health assistance either promoted or hindered SRHR that year.

Action Scoring

The SRHR Index grades actors based on global health actions that are within their control. The term “action” refers to publicly available information related to global health assistance on U.S. government websites. What qualifies as an action is unique for each actor (see the Action & Budget Data by Actor section below for details).

Scoring follows a nine-point scale where a score of one (1) indicates that the action substantially hindered SRHR. A score of five (5) indicates that the action had little or no effect on SRHR, and a score of nine (9) indicates that the action substantially promoted SRHR.

Gender Transformative

To develop the foundation for scoring each action, the SRHR Index Team¹ created Guidelines² that detail the four criteria for scoring within each of the three domains: gender transformative, responsive to need, based in evidence, and consistent with international human rights norms.

Gender Transformative

Programs and policies that address HIV and AIDS, maternal and child health (MCH), and family planning (FP) should be gender transformative, meaning they foster a critical examination of gender norms and dynamics, strengthen or create systems that support gender equality, support or create equitable gender norms and dynamics, and combat inequitable gender norms and dynamics. When grading an action, the SRHR Index considers whether the action is gender exploitative, gender blind, gender accommodating, or gender transformative.³

Responsive to Need

The Guidelines outline the specific topics, issues, or events that help the SRHR Index Team determine whether an action was responsive to need in a given domain and year based on a range of the latest statistical data. For example, the HIV and AIDS Guidelines include the latest global statistics related to HIV incidence, the number of children who newly acquired HIV, the estimated total of people living with HIV (PLHIV), the number of PLHIV accessing antiretroviral therapy (ART), and other global indicators related to the HIV pandemic. The MCH Guidelines contain the latest global maternal mortality ratio estimate, along with the percentage of maternal mortality due to unsafe abortion, and statistics related to pregnancy-related complications, access to antenatal care (ANC), neonatal and newborn health, and the mortality rate and health indicators of children under age five. The FP Guidelines include statistics related to the total number of women of reproductive age, unmet need of FP, and the use of both modern and traditional contraceptive methods. The FP Guidelines also outline the most used modern and traditional methods of contraception globally, as well as by region where data are available.

The Guidelines are updated to reflect current events that impact U.S. global health programs, policies, and other actions. For example, beginning in 2020, the Guidelines were updated to include data regarding the impact of the COVID-19 pandemic on each of the three domains to highlight how U.S. global health programs in each domain should be responsive to need in the context of the pandemic.

Based in Evidence

The Guidelines document the current evidence base related to each of the three domains, including peer-reviewed literature, grey literature, and organizational reports. Most of the evidence in the Guidelines is stated in the form of questions to consider if a given action is informed by evidence. These questions span several different topics, including Programs and Systems, Access and Program Reach, Specific Interventions, Specific Populations, and Health Service Provider Training. For example, here are two questions from the HIV and AIDS Guidelines: Do HIV and AIDS prevention, care, and treatment programs acknowledge the direct and indirect effects of climate change on people’s access to services? Do these programs adapt accordingly after climate-induced disasters?

The SRHR Index also ensures that actions address the SRHR needs of all populations, including LGBTQI+ individuals, migrant populations, sex workers, pregnant and breastfeeding persons, adolescents, and others. To do so, the Guidelines contain questions that reflect the evidence base for global health programs that are designed to serve both general and specific populations.

Consistent with International Human Rights Norms

The Guidelines capture the most recent international human rights norms and standards related to each domain. The Guidelines outline the connections between each of the domains and the following human rights frameworks and norms: Sustainable Development Goal 3, the International Conference on Population and Development (ICPD), and Article 12 of the International Convention on Economic, Social, and Cultural Rights, which recognizes “the right of everyone to the enjoyment of the highest attainable standard of physical and mental health.” In the FP domain, the Guidelines contain details from Articles 12 and 16 of the Convention on the Elimination of all Forms of Discrimination against Women, as those articles outline the protections for access to FP information, education, and services.

Transparency

The SRHR Index also measures the availability of action and budget data based on the expectation that the U.S. government should make information related to U.S. global health assistance available, accessible, and informative. For this reason, the SRHR Index only grades actions and budgetary data that can be accessed via a publicly available URL. The SRHR Index includes a separate transparency scale that indicates the availability of an actor’s action and budget data in each domain in which the actor works.

The transparency of action and budget data is rated on a four-point scale. A score of one (1) indicates that data are unavailable to score this criterion, a score of two (2) or three (3) indicates that data are available but may not be easy to understand or may not include useful information, and a score of four (4) indicates that data are available, easy to understand, and informative. The transparency score is combined with an actor’s action and budget scores to generate a set of grades with transparency by domain, actor, and the U.S. government overall. The transparency grade reflects the quality action or inaction by each actor with regard to SRHR and the availability of data to make this assessment.

A ‘bad’ transparency grade can be interpreted as being reflective of bad policies or insufficient budget allocations related to SRHR in U.S. global health assistance. In addition, an actor can receive a ‘bad grade’ due to insufficient or inadequate data in a particular domain. A ‘good’ transparency grade does not increase an actor’s grade since the SRHR Index does not reward the government for transparency and availability of information. Rather, it simply indicates that an actor’s action and budget data were available, accessible, and informative.

Fòs Feminista recognizes that a lack of available data or insufficient data is not necessarily a reflection of wrongdoing or lack of political will on the part of the U.S. government or a particular actor. Historically, this has been the case with the unavailability of budget data for some actors due to the timing of the SRHR Index grading cycle each year. The U.S. government is expansive, and the amount of data spread across the various entities and agencies is unwieldy. However, the benchmark for holding a government accountable should be available and accessible information.

Determining the Domains

The SRHR Index grades across three domains: HIV and AIDS, MCH, and FP. The SRHR domains were determined by the established definition of sexual and reproductive health (SRH) services, which mirror how 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 by U.S. global health assistance. Each actor’s grade is based on two (2) data sources in each domain in which they work: actions and budgets. The SRHR Index includes budgetary data for the subsequent fiscal year, which runs from October 1st to September 30th for the U.S. government.

Some actions that take place in a year may not fit squarely into any of the three domains, but rather are broadly related to SRHR, such as gender-based violence (GBV) or abortion. In these cases, the actions are graded across all three domains using the same criteria as any other domain-specific action.

Determining the Actors

The SRHR Index grades the actors that are prominent in U.S. global health assistance: the White House, the U.S. Congress, the Department of State, the United States Agency for International Development (USAID), the Department of Health and Human Services (HHS), and the Department of Defense (DoD). Actors only receive a grade for the areas of global health in which they work. Consultations with experts in the field, government sources, and Kaiser Family Foundation (KFF) fact sheets also informed the six actors that are graded by the SRHR Index.

Action & Budget Data by Actor

White House

Executive Orders and Presidential Memoranda

The primary actions used to assess 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 that guide SRHR-related U.S. global health assistance programs and investments.

Public statements issued by, or made on behalf of, the White House are not included in White House grades because they are made across numerous channels and are difficult to track accurately and consistently.

Legislation signed or vetoed

The White House is also graded according to legislation signed or vetoed by the president in a calendar year. Signing or vetoing bills is an overt statement of the White House’s support for, or opposition to, legislation related to SRHR and global health assistance.

Whole-of-government reports

Whole-of-government reports or policies that are related to global health and approved by the White House are graded within the relevant year, as well. Though these actions may not explicitly mention U.S. global health assistance, they indicate the administration’s stance on specific issues that impact SRHR, including but not limited to climate change, global health security, or trafficking in persons.

President’s budget requests

The president’s proposed budget for the next fiscal year is used to assess the White House’s budget score in each domain. The president’s budget request is an expression of the White House’s values and support of, or opposition to, funding for SRHR-related programs and activities through U.S. global health assistance.

HIV and AIDS

The significant U.S. government investments in the President’s Emergency Plan for AIDS Relief (PEPFAR) and the Global Fund to Fight AIDS, Tuberculosis and Malaria (also known as the Global Fund) make the HIV and AIDS domain the domain through which the White House tends to propose the most U.S. global health assistance funds each fiscal year. These two budget lines were selected because they are the two primary mechanisms through which U.S. global health assistance is used to support the international HIV and AIDS response.

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 SRHR through global MCH programs are the United States’ contributions to UNICEF and UNIFEM (now known as UN Women), and the proposed funding amount for USAID’s FP programs. These three budget lines were selected because they are the primary mechanisms through which U.S. global health assistance is used to support international MCH programs. Funding allocated to the Centers for Disease Control and Prevention (CDC) for global immunizations is not included, though funding for Gavi, the Vaccine Alliance is reflected in this budget score, as it is included in USAID’s MCH budget. .

Family Planning

The two budget lines from the president’s budget request used to evaluate the White House on the level to which FP was promoted or hindered through U.S. global health assistance are the proposed funding amount for USAID’s FP programs and the United States’ contributions to the United Nations Population Fund (UNFPA), which are managed by the Department of State. These two budget lines were selected because they are the primary mechanisms through which U.S. global health assistance is used to support international FP programs.

U.S. Congress

Legislation passed or repealed

The action used to assess Congress’s policy-related activities in each domain is the legislation Congress passed or repealed in a calendar year. Since continuing resolution bills are often amended, both stand-alone legislation and any relevant amendments are included for scoring. Enacting or repealing bills is an expression of Congress’s values, 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

Congressional appropriations that are established in a calendar year for the next fiscal year are used to assess Congress’ budget-related activities in each domain. Congressional appropriations are an overt statement of Congress’ priorities and support for, or opposition to, global SRHR in U.S. global health assistance.

HIV and AIDS

The two budget lines from annual Congressional appropriations used to evaluate Congress on how the HIV and AIDS response was promoted or hindered through global health assistance are the enacted funding amounts for the United States’ contributions to the Global Fund and for PEPFAR. These two budget lines were selected because they are the primary mechanisms through which U.S. global health assistance supports the international HIV and AIDS response. The significant investments in PEPFAR and the Global Fund render HIV and AIDS the domain through which the most money is enacted by Congress across the three domains.

Maternal and Child Health

The three budget lines from annual Congressional appropriations used to evaluate Congress on how global MCH programs were promoted or hindered are the United States’ contributions to UNICEF and UNIFEM (now known as UN Women), and the enacted funding amount for USAID’s MCH programs. These three budget lines were selected because they are primary mechanisms through which U.S. global health assistance is used to support international MCH programs. Funding allotted to the CDC for global immunizations is not measured separately, though Gavi is included in USAID’s MCH budget.

Family Planning

The two budget lines from annual Congressional appropriations used to evaluate Congress on how global FP programs were promoted or hindered through U.S. global health assistance are the enacted funding amount for USAID’s FP programs and the United States’ contributions to UNFPA, which are managed through the Department of State. These budget lines were selected because they are the two primary mechanisms through which U.S. global health assistance supports international FP programs.

U.S. Global Health Implementing Agencies

Agencies’ policies and procedures

The SRHR Index grades actions for the following agencies that implement U.S. global health assistance: the Department of State, USAID, HHS, and DoD. Actions for these actors include any policies, procedures, technical or programmatic guidance, implementation plans, strategies, and reports released or updated in a relevant calendar year that are related to global health. These actions are scored in the domains in which they are relevant. Policies, procedures, and other actions are included as an expression of an agency’s values, management, and guidelines related to the delivery of global health programming, as well as an expression of support for, or opposition to, global SRHR.

Agencies’ expenditure of funds

Agencies are graded on the level to which their funding disbursements are responsive to need at the country level by domain. There is a specific methodology for calculating the budget score for each actor within each of the domains in which they work using publicly available data from the World Bank, the World Health Organization (WHO), United Nations (UN) sources, and ForeignAssistance.gov. The budget calculations are unique for each actor and domain. For example, the disbursement of funds in countries with the highest fertility rate, maternal mortality ratio, 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 total fertility rate, maternal mortality ratio, 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 in such a way that maximizes the positive impact of U.S. global health assistance on SRHR globally.

HIV and AIDS

The HIV and AIDS criterion measures the extent to which an agency has disbursed its funds in countries with the highest HIV incidence rates as a proxy to indicate where this funding is needed most in the HIV and AIDS response. ‘Prevalence’ of HIV was not selected as an indicator because data collection methods were not deemed to be as comparable and uniform as HIV incidence data across years and countries.

The HIV and AIDS budget calculation is determined by calculating the spending of HIV and AIDS funding per capita in each country depending on its HIV incidence rate. First, the SRHR Index Team downloads World Bank data with HIV incidence rate 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) by country.⁴ HIV incidence data was only consistently available for this age range, which is a limitation of the methodology. Countries with the highest HIV incidence are typically those above the global average HIV incidence. The SRHR Index Team uses publicly available country population data from the World Bank⁵ and data on the agency’s HIV and AIDS disbursements in a particular fiscal year from ForeignAssistance.gov to determine the amount of global HIV and AIDS funding disbursed in each country per capita.⁶ Based on this information, it is possible to calculate whether these funds were disbursed in the countries with the highest HIV incidence.

Maternal and Child Health

The MCH criterion measures the extent to which agencies spent their global MCH funds in countries with the highest maternal mortality ratios. Complications during pregnancy and childbirth are a leading cause of death and disability around the world. The maternal mortality ratio represents the risk associated with each pregnancy.

The MCH budget calculation for agencies is determined by calculating the level to which global MCH funds were disbursed in countries with the highest maternal mortality ratio that year (or for the most recent year with available maternal mortality ratio data from the World Bank).⁷ Those with the highest maternal mortality ratio are typically those countries with rates higher than the global average maternal mortality ratio. The SRHR Index Team uses publicly available data on the population of women of reproductive age by country from the WHO⁸ and data on the agency’s MCH disbursements in a particular fiscal year from ForeignAssitance.gov⁹ to determine the amount of global MCH funding disbursed in each country per capita. Based on this information, it is possible to calculate whether these funds were disbursed in the countries with the highest maternal mortality ratios.

Family Planning

The FP criterion measures the extent to which agencies spent their global FP funds in countries with the highest total fertility rates. The WHO defines total fertility rate as the total number of children born, or likely to be born, to a person in their lifetime if they were subject to the prevailing rate of age-specific fertility in the population.¹⁰

The FP budget calculation is determined by calculating if global FP funds were spent in the countries with the highest total fertility rate that year (or for the most recent year with available total fertility rate data from the UN).¹¹ Those with the highest total fertility rate are typically those countries above the global average total fertility rate. The SRHR Index Team uses publicly available data from the WHO on the population of women of reproductive age by country¹² and data on the agency’s FP disbursements in a particular fiscal year from ForeignAssistance.gov¹³ to determine the amount of global FP funding disbursed in each country per capita. Based on this information, it is possible to calculate whether these funds were disbursed in the countries with the highest total fertility rates.

Main Data Sources

Qualitative and quantitative data collected for the SRHR Index come from a range of primary and secondary sources, including the InterAction Coalition, the Kaiser Family Foundation (KFF), the World Bank, the WHO, UN data sources, 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, websites, and resources related to U.S. government agency priorities, guidelines, and procedures.

Kaiser Family Foundation (KFF)

The KFF website is a key source for budget-related data, particularly the “U.S. Global Health Budget Tracker” for presidential budgets and Congressional appropriations.¹⁴ 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 budget request and relevant Congressional appropriation bills, as well.

InterAction Coalition

The InterAction Coalition’s budget recommendations were used to develop the SRHR Index methodology to assess budget-related activities for the White House’s budget requests and Congressional 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 funding for global SRHR. The InterAction site has been used as a secondary source for Congressional appropriation numbers by domain for many years.

The World Bank, WHO, and UN

The World Bank, WHO, and UN provide standard data that are used to calculate the budget scores that indicate responsiveness to need (e.g., total fertility rate, maternal mortality ratio, HIV incidence rate, total population, women of reproductive age). They are globally respected sources for global and country-level data. For consistency and transparency, it is good practice for the U.S. government to use statistics provided by these sources when determining the countries where there is the greatest need for global health programming and investments.