Improving tracking of aid for women's, children's, and adolescents' health
Authors: Gavin Yamey, Marco Schäferhoff, Kaci Kennedy
Journal: The Lancet Global Health (2018)

The Sustainable Development Goals (SDGs) established ambitious targets for maternal and child health. SDG target 3.1 aims to reduce the global maternal mortality ratio to less than 70 deaths per 100 000 livebirths, and SDG target 3.2 calls for all countries to reduce their child mortality to less than 25 deaths per 1000 livebirths by 2030. Currently, 79 countries are off track for one or both targets.1McArthur J Rasmussen K Yamey G How many lives are at stake? Assessing 2030 sustainable development goal trajectories for maternal and child health.BMJ. 2018; 360: k373Crossref PubMed Scopus (12) Google Scholar Accelerated progress is urgently needed—if these countries fail to achieve SDG targets 3.1 and 3.2, the lives of 1·6 million mothers and 10·2 million children will be at stake. An estimated US$33 billion in additional annual financing is needed to accelerate progress and meet these goals.2Global Financing FacilityGlobal Financing Facility in Support of Every Woman Every Child. Business Plan. June, 2015. Annex 2: Methodology for the resource needs, financing flows, and health impacts.https://www.globalfinancingfacility.org/sites/gff_new/files/GFF_Business_Plan_FINAL%20web%20version.pdfDate accessed: June 26, 2018Google Scholar Most of this funding will need to come from the governments of low-income and middle-income countries. Nevertheless, aid for reproductive, maternal, newborn, and child health (RMNCH) will still be needed, especially for the poorest countries. Given the stakes—closing the financing gap is a matter of life and death for millions of mothers and children—proper tracking of aid for RMNCH is an essential tool in reaching SDG targets 3.1 and 3.2. Such tracking helps answer several crucial questions. Are donors living up to their commitments? Is aid flowing to the neediest countries? Is the money buying the interventions with the highest impact? A major barrier in tracking aid for RMNCH is the multiplicity of different tracking methods and lack of consensus on which to use. There are four different methods for estimating RMNCH aid levels, flows, and year-on-year trends, each of which has its defenders and critics. These are: Countdown to 2030,3Grollman C Arregoces L Martinez-Alvarez M et al.Developing a dataset to track aid for reproductive, maternal, newborn and child health, 2003–2013.Sci Data. 2017; 4: 170038Crossref PubMed Scopus (11) Google Scholar the Institute for Health Metrics and Evaluation (IHME) approach,4IHMEDevelopment Assistance for Health Database 1990–2016. Institute for Health Metrics and Evaluation, Seattle2017Google Scholar the G8's Muskoka method,5Methodology for calculating baselines and commitments: G8 member spending on maternal, newborn and child health.https://www.ranepa.ru/images/media/g8/2010/Methodology%20for%20Calculating%20Baselines%20and%20Commitments.pdfDate accessed: June 27, 2018Google Scholar and the Organisation for Economic Co-operation and Development (OECD) RMNCH policy marker.6OECDConverged statistical reporting directives for the creditor reporting system (CRS) and the annual DAC questionnaire—addendum 3: reporting instructions for the RMNCH policy marker. Organisation for Economic Co-operation and Development, Paris2014Google Scholar How do these methods stack up against each other? A new study by Catherine Pitt and colleagues7Pitt C Grollman C Martinez-Alvarez M Arregoces L Borghi J Tracking aid for global health goals: a systematic comparison of four approaches applied to reproductive, maternal, newborn, and child health.Lancet Glob Health. 2018; 6: e859-e874Summary Full Text Full Text PDF PubMed Scopus (17) Google Scholar in The Lancet Global Health addresses this question. This study finds that these methods give "substantially different estimates of levels and trends in aid for RMNCH, especially for individual donors and recipient countries." Estimates of global aid for RMNCH in 2013 were $13·1 billion (Countdown), $13·0 billion (Muskoka), $10·8 billion (IHME), and $2·0 billion (OECD RMNCH policy marker). The study found four main reasons why the estimates differ. First, the initiatives use different definitions of what is included in RMNCH. Second, they use different methods to calculate the results. For example, Countdown uses in-depth review of aid project descriptions, whereas Muskoka applies shares to the purpose codes in the OECD aid database (codes that describe the purpose of each aid project)—for example, 40% of aid projects targeting the general population are counted as RMNCH. Third, IHME uses additional data beyond the OECD aid database (eg, on additional private sources). Fourth, unlike the other initiatives, IHME focuses narrowly on health sector aid to RMNCH, excluding funding for health systems, even when such aid would benefit RMNCH. The OECD policy marker—a tag that donors can use in their annual reporting to denote that their aid is being directed to RMNCH—gives a very low estimate because only half of donors use it consistently. Pitt and colleagues assessed the pros and cons of each approach. They found that Countdown is the most in-depth approach, but is slow and labour-intensive. Muskoka is quicker and more adaptable to new goals, but has a higher risk of misclassifying aid because it does not include project-level review. IHME's approach is also quick and adaptable, but uses a narrower view of aid for RMNCH and its methods are "not fully replicable."7Pitt C Grollman C Martinez-Alvarez M Arregoces L Borghi J Tracking aid for global health goals: a systematic comparison of four approaches applied to reproductive, maternal, newborn, and child health.Lancet Glob Health. 2018; 6: e859-e874Summary Full Text Full Text PDF PubMed Scopus (17) Google Scholar Since the OECD RMNCH policy marker is not being implemented by all donors, its estimates are uninformative. How should the global health community move forward in tracking aid for RMNCH? Here, Pitt and colleagues' study is vague, concluding that tracking methods need to make trade-offs between "simplicity, timeliness, precision, accuracy, efficiency, flexibility, and replicability, and the incentives that different metrics create for donors." Policy makers will need more specific guidance than this study provides. Recognising this need, Countdown and the Partnership for Maternal, Newborn & Child Health (PMNCH) convened a consultation to discuss this study and agree on criteria for an improved method to track aid for RMNCH.8Countdown to 2030Partnership for Maternal Newborn & Child HealthStrengthening the tracking of official development assistance and domestic financing for women's, children's and adolescents' health. Joint Consultation.http://www.who.int/entity/pmnch/media/news/2018/Financial-Tracking-Meeting-report.pdf?ua=1Date: May 10–11 2018Date accessed: June 26, 2018Google Scholar The consultation concluded that this improved method should enhance the existing Muskoka approach (Muskoka 2.0) and aim to achieve three Cs: credibility in its methods, comprehensiveness in what it captures, and comparability (the ability to track aid across different donors and recipients). A joint Countdown and PMNCH technical working group, together with the London School of Hygiene & Tropical Medicine, will further develop the Muskoka 2.0 method and will address other crucial RMNCH financing questions. As discussed at the consultation, any new method will need to grapple with the changing financing landscape in global health. One question is, how can a method link the tracking of aid for RMNCH with broader efforts to track funding for universal health coverage and domestic health spending? To be timely and relevant, Muskoka 2.0 should capture aid from Brazil, China, India, and other emerging donors (none of the current methods do so). If Muskoka 2.0 gets it right, we will hopefully enter a new era of accountability, in which we can more accurately track spending on RMNCH by donors and low-income and middle-income governments and, ultimately, accelerate progress in reducing maternal and child deaths worldwide. MS has worked with the Partnership for Maternal, Newborn & Child Health (PMNCH) and used the Muskoka method for PMNCH reports, and Catherine Pitt and colleagues contacted him during their study to discuss this work. GY, MS, and KK were funded by PMNCH for an analysis of commitments made to the Global Strategy for Women's, Children's, and Adolescents' Health. MS co-organised the Countdown-PMNCH consultation mentioned in this Comment (Pitt and colleagues presented their paper at this event); MS and KK attended the consultation. MS will co-chair the technical working group on tracking aid for the health of women, children, and adolescents. KK previously worked at the Bill & Melinda Gates Foundation, a funder of the Countdown initiative and of IHME. KK and GY are currently funded by the Gates Foundation. Tracking aid for global health goals: a systematic comparison of four approaches applied to reproductive, maternal, newborn, and child healthThe four approaches are likely to lead to different conclusions about whether individual donors and recipient countries have fulfilled their obligations and commitments and whether aid was sufficient, targeted to countries with greater need, or effective. We recommend that efforts to track aid for the Sustainable Development Goals reflect their multisectoral and interconnected nature and make analytical choices that are appropriate to their objectives, recognising the trade-offs between simplicity, timeliness, precision, accuracy, efficiency, flexibility, replicability, and the incentives that different metrics create for donors. Full-Text PDF Open Access