Agreement: I Agree Body: Waris and colleagues propose a global fiscal institution to support sexual and reproductive health and rights (SRHR).1 They acknowledge that the relation between spending and outcomes is complex. Evaluating the proposal raises a narrower question: how would improved access be assessed among people who never reach a service? An assessment confined to recorded users could overlook the unmet demand that additional fiscal capacity is intended to address. A budget execution rate describes expenditure relative to an approved budget; it does not establish what services people received.2 For contraception, higher spending and more consultations could coexist with persistent inability to obtain a preferred, clinically appropriate method. Disaggregating attendance by age or income would not resolve this problem if people excluded before attendance remain uncounted. WHO guidance links reducing unmet need with respecting and protecting human rights.3 Measurement should therefore distinguish wanted but inaccessible contraception from a voluntary decision not to use it. Could the authors provide a worked example linking fiscal changes to access among people who want contraception, rather than only existing users? Approved allocations, releases of funds, and actual expenditure could be examined alongside method availability and population survey reports of cost or supply barriers. Such an example should specify which measures the proposed institution would assess and which national bodies would investigate gaps between funding and access. Using existing surveys, where suitable and with confidentiality safeguards, could limit reporting burdens; disaggregating results by age, socioeconomic position, and location would describe distribution. These measures would trace implementation, not establish that fiscal reform caused improved access or capture all dimensions of SRHR. Evidence of greater fiscal capacity is not, by itself, evidence that unmet demand has fallen. References 1. Waris A, Bohoslavsky JP, Ooms G, Hammonds R. International fiscal architecture for advancing sexual and reproductive health and rights. BMJ 2026;394:e100595. doi:10.1136/bmj-2026-100595. 2. Piatti-Fünfkirchen M, Barroy H, Pivodic F, Margini F. Budget execution in health: concepts, trends and policy issues. Washington, DC: World Bank; 2021. 3. World Health Organization. Ensuring human rights in the provision of contraceptive information and services: guidance and recommendations. Geneva: World Health Organization; 2014. No competing Interests: Yes The following competing Interests: Electronic Publication Date: Saturday, October 3, 2026 - 18:11 AI use: No, I have not used AI Highwire Comment Subject: International fiscal architecture for advancing sexual and reproductive health and rights Workflow State: Released Full Title: Fiscal reform and reproductive health: measuring access beyond service users Highwire Comment Response to: International fiscal architecture for advancing sexual and reproductive health and rights Check this box if you would like your letter to appear anonymously:: Last Name: Liu First name and middle initial: Jia Email: jliu6197@gmail.com Address: No. 818, Renmin Road, Wuling District, Changde City, Hunan Province, China Occupation: Physician Affiliation: Changde Hospital, Xiangya School of Medicine, Central South University (The First People's Hospital of Changde City) BMJ: Additional Article Info: Rapid response
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