By Sabrina Natasha Premji and Afzal Habib
At the Saving Every Woman, Every Child summit held in Toronto, Canada last month, Dr. Jim Yong Kim, president of the World Bank Group asserted, “We stand today on a critical threshold for global health and development. While we can absolutely point to progress, we know that it has been uneven. Too many women and children are still dying because they lack access to quality health care…”
This view was echoed by the summit’s high profile delegates which included United Nations Secretary General Ban Ki Moon, World Health Organization President Dr. Margaret Chan, His Highness the Aga Khan, and Melinda Gates.
The event’s host, Canadian Prime Minister Stephen Harper, announced a $3.5 billion commitment by the Canadian government to support maternal and child health initiatives globally from 2015-2020, building off the previous $2.8 billion commitment announced at the Muskoka G8 summit in 2010. The funds will be primarily directed towards immunization and nutrition initiatives, as well as building effective vital statistics and civil registries.
But missing from the summit were discussions on reproductive health and family planning, including abortion services, a fact that critics are quick to attribute to the current Canadian Government’s conservative leanings. This is particularly relevant given that in the summit’s co-host country of Tanzania, the second leading cause of maternal death is unsafe abortions.
Conference attendees of the Saving Every Woman, Every Child summit.
The noticeable gap between what is being funded and the challenges on the ground prompts us to ask, who really owns the maternal, newborn, and child health agenda? By ownership, we mean who sets the strategic priorities and who is held accountable if results are not seen?
Ownership generally follows the money, and since the Canadian government is the lead funder, it is calling the shots. They are able to determine the key priorities, as well as implement partners and timelines within recipient countries.
Not to be misunderstood, the Canadian government doubling-down on issues of maternal and child health is admirable, particularly when the international community is at the brink of defining its post-2015 development agenda. However, if the strategic planning process is not equally shared by governments of low-income countries, with buy-in and commitments from these local governments to allocate their own resources to the cause, Mr. Harper’s largesse quickly spirals from admirable to problematic.
Indeed, when the pipeline of official development assistance eventually runs dry, it is the local governments of lower-income countries that will be in charge of financing health interventions to sustain the gains made. It is the local governments who must, therefore, focus on establishing the appropriate operational and financial infrastructure now to be able to support initiatives in the long-run. It is the local governments that must champion the maternal and child health agenda in their respective regions.
In response to Canada’s decision to exclude reproductive health in its top three maternal and child health priority items, His Excellency President Jakaya Kikwete of Tanzania said, “We don’t expect Canada to fund everything related to saving the lives of women and children.”
Instead of noting the shortfall being covered by his government’s own resources or brainstorming other innovative financing mechanisms, President Kikwete continued, "…We have many partners. So I think if Canada chooses not to fund contraceptives, we will not take offence for that.”
His Highness the Aga Khan had a different view: “We cannot sustain programs that depend on continuing bursts of outside money. Sustainable success will depend on a strong sense of local ownership.”
We certainly hope that local governments were listening. The Tanzanian government, for example, has only allocated 9 percent of its total budget to health care, short of the 15 percent target agreed upon in the WHO’s 2001 Abuja Declaration, of which a meager 6.3 percent goes to maternal and child health programs.
Realistically, what is the incentive for governments like Tanzania to champion solutions to their health challenges when their situation is perfectly adept to receiving funding externally? Often, as countries develop economically and see marginal improvements on health indicators, they can become less attractive to receive donor funding which favors the poorest nations, putting greater pressure on their ill-equipped national budgets.
“Missing from the policy discussion is financing and particularly, domestic financing,” says Dr. Mickey Chopra, Chief of Health and Associate Director of Programs at UNICEF. “We’ve always assumed it would come from domestic taxation, but that infrastructure doesn’t exist today.”
Dr. Chopra hypothesizes that the impetus for local ownership and long-term sustainability will come from driving demand at the community level: “Historical experience suggests that as countries become wealthier and more developed, there generally tends to be a natural progression to spend more or care more about health. We can get to a win-win where we have leaders re-elected for improving service provision.”
Canadian Prime Minister Steven Harper, World Bank President Dr. Jim Yong Kim, WHO Director-General Dr. Margaret Chan, USAID Administrator Dr. Rajiv Shah, CEO of PLAN Canada Rosmary McCarney, in the silhouette of Tanzanian President Jakaya Kikwete’s Security Detail.
The issue with trusting local demand to sustain the momentum of maternal and child health, as Dr. Chopra says, is that “governments don’t generally stand on saying we’ll reduce mortality. They typically run on we’ll provide more services.”
New maternity clinics with untrained staff and frequent drug stock-shortages are hardly an effective approach to reducing maternal and child deaths.
The World Bank’s Dr. Jim Yong Kim is more optimistic. There are now opportunities to leverage various forms of financing in tandem, including grant funding, domestic resources, low-interest loans, and public-private partnerships: “We can come up with a vision for how to fund these processes that will really stretch people’s imaginations,” he said.
This innovative blend of bridge financing can yield remarkable long-term results. In the Republic of Congo, for example, the government recently contributed $100 million from its own domestic budget, accounting for approximately 80 percent of the total cost to scale-up maternal and child health services nation-wide.
The Republic of Congo, however, represents a single success story, with the vast majority of developing nations still heavily dependent on foreign assistance to meet their significant health challenges.
The Saving Every Woman, Every Child summit represents one of a multitude of global conversations to take place over the coming months on tackling maternal and child health issues in a post-2015 development era. Let us ensure that local governments are setting the priorities, driving the agenda based on their needs, and making smart investments in the architecture of their health systems to support long-term impact.
If we fail to do so, we may find ourselves 20 years from now, holding the same summits and discussing the same issues, while the lives of millions of mothers and children hang in the balance.
Sabrina Natasha Premji and Afzal Habib are co-founders of Kidogo Early Years, a social enterprise providing high-quality, affordable early childhood care and education in East Africa’s urban slums.