Thirty years ago, the world came together in Cairo for the very first International Conference on Population and Development. Coming in the wake of the Rwandan genocide, which had catastrophic consequences for women and girls, the international community publicly recognised for the first time the undeniable link between reproductive rights and development. This led to a set of shared goals for gender equality, with bold commitments to improving conditions for women and girls. 

Thirty years on, these commitments have not only not been met, but things are getting worse. Today, 72 million women and girls of reproductive age require humanitarian assistance. These numbers are likely to continue to rise, as will the urgent need for sexual and reproductive health services (SRH), as limited resources and multiple, overlapping crises have thrown women and girls into periods of sustained turmoil.

Three decades after the promise of Cairo 1994, a perfect storm is gathering, with the countries that need SRH help the most seeing the least humanitarian aid. Among the ten countries with the highest maternal and newborn mortality ratios, a majority have unmet 2024 appeals for assistance. The countries with active 2024 appeals for humanitarian assistance are home to just 13 percent of the global population, but account for 58 percent of global maternal deaths, 37 percent of newborn deaths, 36 percent of stillbirths, and 25 percent of women with an unmet need for family planning.

Even worse, these figures are likely low, as they reflect pre-crisis data from recent emergencies like Gaza, Sudan, Myanmar, and Ukraine. From conditions faced by the 50,000 pregnant women in Gaza, to sexual violence and rape in Sudan to women giving birth in darkness and silence to ensure their safety in Myanmar and Ukraine, women in crisis situations face almost incomprehensible sexual and reproductive health burdens.

Given these circumstances, you’d expect large-scale investment and attention from donors and coalitions. But the money hasn’t materialised. Today only 19 percent of family planning dollars and 29 percent of sexual health dollars go to conflict-affected countries. Conflict-affected countries actually received the least SRH assistance per capita between 2013 and 2022.

Why? Clearly insufficient funding for humanitarian settings is an important contributor to poor outcomes for women, but it is not the complete picture. Four key myths are driving this crisis.

Myth #1: ‘It’s not feasible.’

Tools for delivering SRH services exist and are proven, even in the most difficult settings. In 1996, the Interagency Working Group for Reproductive Health in Crises (IAWG) developed the ‘Minimum Initial Services Package for SRH in Crisis Situations,’ (MISP) a set of lifesaving, priority activities that should be delivered at the onset of a crisis. While the MISP has been the global standard of care for more than thirty years, too often donors, governments, and implementers claim either that it is ‘too hard’ or that ‘there is no demand’ for these services in emergencies.

However, my organisation, the International Rescue Committee (IRC), demonstrated that the MISP is feasible in complex emergencies. From 2013-2020, we supported the implementation of twenty-two MISP responses in fourteen countries using a flexible fund. This allowed IRC to immediately deploy SRH staff and aid.

Myth #2: ‘It’s not a priority.’

Despite decades of advocacy, progress on funding SRH in humanitarian settings is stalled. Humanitarian actors too often continue to prioritise other interventions, leading to dire reproductive, maternal and newborn health outcomes in countries experiencing humanitarian emergencies. Indeed, a majority of the countries with the highest maternal and newborn mortality ratios and low contraceptive use are experiencing active emergencies.

And when donors and governments do prioritise SRH in policy, insufficient funding forces difficult choices across sectors, making it easier for responders to sideline the more sensitive SRH services when funding is tight, and stigma is high. Indeed, many private funders seem to either assume SRH is covered entirely by humanitarian donors or believe that it should be, claiming these needs for people in crises is outside their scope.

Overcoming entrenched barriers to progress in SRHR in countries affected by crises requires more investment and stronger accountability for implementation in the sub-national regions with the worst outcomes and most frequent crises. 

Myth #3: ‘It’s too expensive.’

One of the most common reasons mentioned by private foundations for not investing in humanitarian settings is that there is a perceived low return on investment, i.e., they can spend less to reach more people in stable settings. However, another important, yet unanswered, question is, what are the human and development costs of not investing in SRH in conflict zones?

Recent cost analyses have shown that it is possible to effectively invest in SRH for underserved women and girls in humanitarian settings. One recent study analysed the implementation costs of family planning programs in ten countries between 2015-2023. Preliminary data indicated that the average cost per CYP (‘couple-years of protection’) across these programs was approximately $45, which is two- to three-times higher than the cost in low-income stable settings.

However, this changed when leveraging economies of scale over several years. Through investing in community engagement, building service provider capacity, and providing the full range of family planning methods over at least three years, programs were able to achieve high scale and incur lower costs in the subsequent years. For example, a multi-year family planning program in Somalia cost $123 per CYP in year two, which decreased by more than 80 percent to $17 per CYP in year five. We can afford it – and we can’t afford not to.

Myth #4: ‘It’s not sustainable.’

Many donors rightfully prioritise shifting power to local organisations and strengthening systems, but also hold the perception that humanitarian programming is at odds with these priorities. in fact, a common misconception is that response programming only involves direct service delivery by international non-profits (INGOs), usually in refugee camps. The truth is that most programming exists within national and sub-national health systems – supporting Ministries of Health to improve service delivery. Indeed, only 5-10 percent of health facilities supported by the IRC at any given time are in designated refugee camps.

Importantly, humanitarian programming includes emergency preparedness within protracted crises, advocacy for the rights of affected population, and the implementation of national guidelines – in other words, longer-term systems change. However, the humanitarian organisations working in these settings too often must rely on dwindling, 12-month cycles of humanitarian funding which are not designed to strengthen and transform systems.

Humanitarians are testing new and effective models for bridging this divide. As part of the Shifting Paradigms in SRHR in Emergencies (SHIFT) project, IRC partnered with OTOBPFE in Chad and Agency for Cooperation, Research and Development (ACORD) and Women and Rural Development Network (WORUDET) in Uganda to strengthen local capacity in MISP preparedness and response. As a result, when the Sudan refugee crisis hit Eastern Chad in 2022, we were able to effectively respond together within forty-eight hours.

Similarly, as part of the six-year FCDO-funded, International Planned Parenthood Federation-led WISH2ACTION project in East Africa, the IRC served as the humanitarian partner, ensuring crisis-affected populations were centred in the project strategy. By working closely with development and government partners to ensure humanitarian populations were not left behind, 700,000 women and adolescent girls in humanitarian settings accessed family planning, among whom 56 percent had never used a method before, resulting in the prevention of 187,000 unintended pregnancies. It can be done.

Thirty years ago, the world came together to set an ambitious agenda to achieve gender equality and sexual and reproductive health and rights. Today, as crises worsen, the achievement of this vision requires that we centre the needs of those affected by crises – and that we invest. These efforts will require dedicated funding and strong accountability mechanisms. But most importantly, these efforts require setting aside the myths that hold back progress for millions of women.

Erin Wheeler is Global Practice Lead, Sexual and Reproductive Health and Rights at the International Rescue Committee.