Rethinking the global tracking system on development assistance to reproductive, maternal, newborn, and child health
Authors: Sarah Krull Abe, Yuki Murakami, David Morgan, Kenji Shibuya
Journal: The Lancet Global Health (2015)

Tracking of spending on reproductive, maternal, newborn, and child health (RMNCH) is key to monitoring progress towards Millennium Development Goals (MDGs) 4 and 5 to reduce child mortality and improve maternal health. The Organisation for Economic Co-operation and Development's development assistance committee tracks bilateral and multilateral official development assistance (ODA) and other resource flows, including private donors, such as the Bill & Melinda Gates Foundation1Institute for Health Metrics and EvaluationFinancing Global Health 2013: Transition in an Age of Austerity. IHME, Seattle, WA2014Google Scholar—so-called ODA+—under the credit reporting system database. Commitments and disbursements are tracked at both the aggregate level and at the level of particular aid programmes. The importance of measurement of progress and ensuring accountability has been increasingly discussed after the Paris Declaration on Aid Effectiveness. Within this context, in this issue of The Lancet Global Health, the new study by Leonardo Arregoces and colleagues2Arregoces L Daly F Pitt C et al.Countdown to 2015: changes in official development assistance to reproductive, maternal, newborn, and child health, and assessment of progress between 2003 and 2012.Lancet Glob Health. 2015; 3: e410-e422Summary Full Text Full Text PDF Scopus (41) Google Scholar is the latest in a long series of analyses on resource tracking of RMNCH,3Pitt C Greco G Powell-Jackson T Mills A Countdown to 2015: assessment of official development assistance to maternal, newborn, and child health, 2003–08.Lancet. 2010; 376: 1485-1496Summary Full Text Full Text PDF PubMed Scopus (74) Google Scholar, 4Hsu J Pitt C Greco G Berman P Mills A Countdown to 2015: changes in official development assistance to maternal, newborn, and child health in 2009–10, and assessment of progress since 2003.Lancet. 2012; 380: 1157-1168Summary Full Text Full Text PDF PubMed Scopus (81) Google Scholar focusing on evaluating whether donor funding is well targeted to countries with the greatest need. In their comprehensive study, Arregoces and colleagues report that, although overall levels of ODA+ funding decreased, funding for RMNCH increased in 2011 and 2012. External resources still account for 16·4% of total health spending in low-income countries and 9·5% in countries in Africa.5Morgan D Murakami Y Ravishankar N Njuguna D Strengthening resource tracking and monitoring health expenditure. OECD, Paris, France2014http://www.oecd.org/health/health-systems/Strengthening-Resource-Tracking-and-Monitoring-Health%20Expenditure_Final-Report.pdfGoogle Scholar This finding has implications for the sustainability and fungibility of programmes and is vital to better understand the trend of the sources and level of supports.2Arregoces L Daly F Pitt C et al.Countdown to 2015: changes in official development assistance to reproductive, maternal, newborn, and child health, and assessment of progress between 2003 and 2012.Lancet Glob Health. 2015; 3: e410-e422Summary Full Text Full Text PDF Scopus (41) Google Scholar, 6Oliveira-Cruz V Kurowski C Mills A Delivery of priority health services: searching for synergies within the vertical versus horizontal debate.J Int Dev. 2003; 15: 67-86Crossref Scopus (91) Google Scholar Despite a wealth of research based on available datasets, questions remain regarding the fragmentation of funding:6Oliveira-Cruz V Kurowski C Mills A Delivery of priority health services: searching for synergies within the vertical versus horizontal debate.J Int Dev. 2003; 15: 67-86Crossref Scopus (91) Google Scholar, 7Piva P Dodd R Where did all the aid go? An in-depth analysis of increased health aid flows over the past 10 years.Bull World Health Organ. 2009; 87: 930-939Crossref PubMed Scopus (62) Google Scholar how should aid be disbursed? What modality and approaches are most effective—eg, project-oriented, general budget, or multisectoral in terms of outcomes and outputs? What is the linkage between disbursement and actual spending? This study provides a useful contribution to whether programme specific-funding has been targeted to those countries with the greatest needs. Yet there remains room for more international efforts to further investigate the aforementioned questions. The study by Arregoces and colleagues2Arregoces L Daly F Pitt C et al.Countdown to 2015: changes in official development assistance to reproductive, maternal, newborn, and child health, and assessment of progress between 2003 and 2012.Lancet Glob Health. 2015; 3: e410-e422Summary Full Text Full Text PDF Scopus (41) Google Scholar raises the importance of harmonising international collaboration across various resource-tracking initiatives. This is welcome and highlights the need to fill existing gaps and agree on a standardised method. The current credit reporting system method broadly categorises each fund and has limits as to different health-care activities—for example, prevention and treatment of HIV/AIDS among pregnant women can be either categorised under maternal health or HIV/AIDS programmes. On the other hand, the Institute for Health Metrics and Evaluation excludes malaria, tuberculosis, and HIV/AIDS programmes from its estimate on aid for maternal, newborn, and child health. The assumptions around the allocation to RMNCH from general budget support could also be worthy of further examination. There is no doubting the importance of ODA in health generally, and more specifically for RMNCH. Countries and external funds have competing priorities in allocating restricted funds. It is also important to ensure comprehensiveness, and the study rightly raises the issue of some of the data gaps. Efforts should be made to include all missing data, wherever possible, from countries that are not members of the development assistance committee (such as China and Middle Eastern countries), major donor non-governmental organisations, and foundations, to ensure that public and private influences on the direction of ODA programmes are properly understood. For example, China contributes as much as US$4 billion in aid annually and is increasingly influential in Africa,8Grepin KA Fan VY Shen GC Chen L China's role as a global health donor in Africa: what can we learn from studying under reported resource flows?.Global Health. 2014; 10: 84Crossref PubMed Scopus (35) Google Scholar but was not included in this study.2Arregoces L Daly F Pitt C et al.Countdown to 2015: changes in official development assistance to reproductive, maternal, newborn, and child health, and assessment of progress between 2003 and 2012.Lancet Glob Health. 2015; 3: e410-e422Summary Full Text Full Text PDF Scopus (41) Google Scholar On a similar note, understanding the roles of both external and domestic funding is vital—more than half of all RMNCH funding for the 75 Countdown countries comes from domestic sources.9The Partnership for Maternal, Newborn & Child Health. The PMNCH 2014 accountability report: tracking financial commitments to the global strategy for women's and children's health: PMNCH, 2014.Google Scholar The long-term goal of independence of recipients and sustainability of projects must remain at the forefront of all programmes. The post-2015 Sustainable Development Goals (SDGs) have been criticised as being too general and impractical,10Horton R Offline: why the sustainable development goals will fail.Lancet. 2014; 383: 2196Summary Full Text Full Text PDF Scopus (36) Google Scholar and as we move into the SDG era this study has identified a need for new funding pathways related to RMNCH.2Arregoces L Daly F Pitt C et al.Countdown to 2015: changes in official development assistance to reproductive, maternal, newborn, and child health, and assessment of progress between 2003 and 2012.Lancet Glob Health. 2015; 3: e410-e422Summary Full Text Full Text PDF Scopus (41) Google Scholar Here is a dilemma: the most important aspect of the SDG era is not only a chance for the global health community to work together, but also the opportunity to connect sectors. This would include a possible move from currently dominant project-oriented funding to health system strengthening in which delivery of RMNCH services should be essential. Greater efforts are also needed to prevent donor aid from displacing national funding for programmes,11Farag M Nandakumar AK Wallack SS Gaumer G Hodgkin D Does funding from donors displace government spending for health in developing countries?.Health Aff (Millwood). 2009; 28: 1045-1055Crossref PubMed Scopus (72) Google Scholar and governments of developing countries must be more involved in global health initiatives,12Sridhar D Seven challenges in international development assistance for health and ways forward.J Law Med Ethics. 2010; 38: 459-469Crossref PubMed Scopus (40) Google Scholar but such involvement and planning needs detailed and robust analysis. A wealth of studies exists for tracking ODA,1Institute for Health Metrics and EvaluationFinancing Global Health 2013: Transition in an Age of Austerity. IHME, Seattle, WA2014Google Scholar, 3Pitt C Greco G Powell-Jackson T Mills A Countdown to 2015: assessment of official development assistance to maternal, newborn, and child health, 2003–08.Lancet. 2010; 376: 1485-1496Summary Full Text Full Text PDF PubMed Scopus (74) Google Scholar, 4Hsu J Pitt C Greco G Berman P Mills A Countdown to 2015: changes in official development assistance to maternal, newborn, and child health in 2009–10, and assessment of progress since 2003.Lancet. 2012; 380: 1157-1168Summary Full Text Full Text PDF PubMed Scopus (81) Google Scholar but few go into any depth to analyse the linkages between ODA and outcomes or effectiveness. The article by Arregoces and colleagues explores this area through its analysis of the relation between ODA+ on RMNCH and health outcomes in child mortality and other related health outcomes.2Arregoces L Daly F Pitt C et al.Countdown to 2015: changes in official development assistance to reproductive, maternal, newborn, and child health, and assessment of progress between 2003 and 2012.Lancet Glob Health. 2015; 3: e410-e422Summary Full Text Full Text PDF Scopus (41) Google Scholar This analysis leads the way for further research to be done to link more directly to outcomes, and to find innovative ways to analyse relations between programme funding, national funding, and delivery metrics. It also supports further development of more comprehensive and detailed tracking of resources through a health accounting framework. The health of mothers, newborns, and children lies at the heart of a healthy productive society. Such a society will take enhanced, collaborative, and comprehensive efforts in research on all major funding sources linked with outcomes and effective project and policy implementation. A comprehensive understanding of global aid flows, and robust data supporting analyses such as this, is essential to ensure that ODA for health continues to be transparent, sustainable, and responsive to the goals of the global health community rather than the funding nations. Through better research we can build on the MDG experience to ensure that ODA works for their benefit in the SDG era. We declare no competing interests. Countdown to 2015: changes in official development assistance to reproductive, maternal, newborn, and child health, and assessment of progress between 2003 and 2012Despite a reduction in ODA+ in 2011, ODA+ to RMNCH increased in both 2011 and 2012. The increase in funding is encouraging, but continued increases are needed to accelerate progress towards achieving MDGs 4 and 5 and beyond. Full-Text PDF Open Access