What counts as development assistance for reproductive, maternal, newborn, and child health?
Authors: Tara Templin, Eran Bendavid
Journal: The Lancet Global Health (2020)

Why should we track development assistance for reproductive, maternal, newborn, and child health (RMNCH)? There is no single answer to this question, and therefore no single way to do it. In The Lancet Global Health, Antonia Dingle and colleagues1Dingle A Schäferhoff M Borghi J et al.Estimates of aid for reproductive, maternal, newborn, and child health: findings from application of the Muskoka2 method, 2002–17.Lancet Glob Health. 2020; 8: e374-e386Summary Full Text Full Text PDF PubMed Scopus (4) Google Scholar report the convening of a group of policy makers to discuss why we should track financing for RMNCH. The group developed a set of principles guiding what information an aid tracking tool would ideally include. The authors present this tool—the Muskoka2 method—for tracking RMNCH aid, along with estimates of RMNCH development assistance from 2002 to 2017. A notable component of Dingle and colleagues' approach is the transparency of the decisions made in the process of estimating RMNCH development assistance. The authors examined disbursements, or the amounts actually transferred in the form of development assistance (rather than commitments, or the amounts that source countries or institutions promise to spend), by collecting project-level data from the Organisation for Economic Co-operation and Development's (OECD's) Creditor Reporting System. The authors tracked funds that originated within a country or foundation, and were given to a multilateral organisation, such as Gavi, the Vaccine Alliance, or the Global Fund, separately from bilateral disbursements, which prevents double counting of assistance that passes through multilateral organisations. Finally, to identify RMNCH projects, the authors assigned a proportion of development assistance for HIV/AIDS, malaria, health-system strengthening, water and sanitation, and humanitarian activities to RMNCH. The authors found that, across this 15-year time period, total aid for RMNCH increased from roughly US$3·2 billion to $15·9 billion. Of the total amount of spending in 2017, the largest share went to child health ($7·4 billion, 46%), followed by reproductive health ($5·4 billion, 34%) and maternal and newborn health ($3·1 billion, 19%). Tracking development assistance for RMNCH is complicated, and the decisions made by Dingle and colleagues serve to highlight some of them. First, the decision as to what to qualify as spending on RMNCH must be made, which could include spending on improving social and environmental factors (in addition to spending to avert direct causes of poor health and disease).2Gakidou E Cowling K Lozano R Murray CJ Increased educational attainment and its effect on child mortality in 175 countries between 1970 and 2009: a systematic analysis.Lancet. 2010; 376: 959-974Summary Full Text Full Text PDF PubMed Scopus (384) Google Scholar Does development assistance for building schools or peace-keeping operations3Wagner Z Heft-Neal S Bhutta ZA Black RE Burke M Bendavid E Armed conflict and child mortality in Africa: a geospatial analysis.Lancet. 2018; 392: 857-865Summary Full Text Full Text PDF PubMed Scopus (49) Google Scholar count as health spending? If we restrict our attention to the health sector, as categorised by the OECD, a common policy question is how development assistance is allocated to different health priority areas, such as HIV/AIDS or RMNCH. As with education or peace-keeping, the boundary between RMNCH and HIV/AIDS development assistance can be porous. Although the framework proposed in Muskoka2 is transparent, the incentives for the policy makers and stakeholders engaged in crafting the framework are less so. The authors make clear that a different group of policy makers might have advocated for a different set of funding categories to be included in Muskoka2. One is left wondering about the unstated interests leading to the particular definitions of RMNCH funding selected into Muskoka2; some ways of organising the funding trends would signal great success, whereas others could suggest a substantial need for additional aid. Although the aforementioned motivations are understandable, they are not always perfectly aligned with providing an accurate presentation of the trends in aid provision. The intensive stakeholder process is laudable in many ways, but the extent to which stakeholder motivations might have influenced the final picture of funding streams that support RMNCH becomes unclear. The authors developed the Muskoka2 method for RMNCH, but not for other areas of health. In other words, this method provides a partial view of the health aid landscape. Because the funding allocation decisions used in Muskoka2 were ad-hoc, it cannot be readily adapted for other purposes. The description of funding for RMNCH is therefore not comparable to other health priorities, making Muskoka2 adept for instututions focusing solely on RMNCH, but of less use to institutions making difficult trade-offs among competing priorities, such as HIV/AIDS, tuberculosis, and non-communicable diseases. If a similar method were used for each health priority, and the total funds for health were calculated, the aggregate would probably be substantially higher than the amount of development assistance actually available to countries. Additionally, institutions would be encouraged to double-count their funds. For example, donors supporting prevention of mother-to-child transmission programmes might allocate this funding as supporting RMNCH activities as well as HIV/AIDS, inflating the amount of aid that is actually received overall, whereas programmes that do not fall into multiple categories of health priority might appear to be underfunded. This work provides valuable insight into the needs of policy makers focusing on RMNCH and suggests a challenge: policy makers want one source or scorecard to consult. Finding one definition that all stakeholders agree on can be challenging, and thus it is impressive that Muskoka2 achieves this consensus. However, as scientists and medical practitioners, we often consider different methods with different assumptions in answering the same question. Indeed, there are already alternative sources with different methodologies for tracking RMNCH aid, such as the OECD's RMNCH policy marker,4OECDConverged statistical reporting directives for the Creditor Reporting System (CRS) and the annual DAC questionnaire. Organisation for Economic Co-operation and Development, Paris2016Google Scholar the Institute for Health Metrics and Evaluation,5Global Burden of Disease Health Financing Collaborator NetworkPast, present, and future of global health financing: a review of development assistance, government, out-of-pocket, and other private spending on health for 195 countries, 1995–2050.Lancet. 2019; 393: 2233-2260Summary Full Text Full Text PDF PubMed Scopus (120) Google Scholar and individual author efforts.6Bavinger JC Wise P Bendavid E The relationship between burden of childhood disease and foreign aid for child health.BMC Health Serv Res. 2017; 17: 655Crossref PubMed Scopus (3) Google Scholar There may be a tension between reproducible, rigorous science, and effective strategies for policy making; such tensions deserve more explicit consideration. Although Dingle and colleagues define RMNCH funding inclusively, the monetary amounts are still less than the projected $33·3 billion that is needed yearly to reach RMNCH and adolescent health goals.7Global Financing FacilityAnnex 2: methodology for the resource needs, financing flows, and health impacts.in: Global Financing Facility in support of Every Woman Every Child: business plan. Global Financing Facility, Washington, DC2015Google Scholar This shortfall highlights the urgency of research on this topic, not only on tracking funds targeted to reach these goals, but also on the efficacy of these funds. This report suggests a number of ways forward for improving the counting of RMNCH aid. At the same time, it emphasises the need to reconcile scientific ideals with policy implementation and the trade-off between simplicity and rigour. We declare no competing interests. Estimates of aid for reproductive, maternal, newborn, and child health: findings from application of the Muskoka2 method, 2002–17Muskoka2 retains the speed, transparency, and donor buy-in of the G8's previous Muskoka approach and incorporates eight innovations to improve precision. Although aid for RMNCH increased in 2017, low-income and middle-income countries still experience substantial funding gaps and threats to future funding. Maternal and newborn health receives considerably less funding than reproductive health or child health, which is a persistent issue requiring urgent attention. Full-Text PDF Open Access