TRANSLATING RECOMMENDATIONS INTO ACTION · women’s and children’s health. This report is the second progress update on the implemen - tation of the 10 recommendations. 2. There

Commission on information and accountability for

Women’s and Children’s Health

TRANSLATING RECOMMENDATIONSINTO AC TION

Y E AR T WO: JULY 2012 – MAY 2013

R E P O R T O N P R O G R E S S T O WA R D S I M P L E M E N T I N G T H E C O M M I S S I O N O N I N F O R M AT I O N

A N D A C C O U N TA B I L I T Y R E C O M M E N D AT I O N S

Commission on information and accountability for

Women’s and Children’s Health

TRANSLATING RECOMMENDATIONSINTO AC TION

Y E AR T WO: JULY 2012 – MAY 2013

R E P O R T O N P R O G R E S S T O WA R D S I M P L E M E N T I N G T H E C O M M I S S I O N O N I N F O R M AT I O N

A N D A C C O U N TA B I L I T Y R E C O M M E N D AT I O N S

ii TRANSLATING RECOMMENDATIONS INTO ACTION

© World Health Organization 2013

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YEAR TWO: JULY 2012–MAY 2013 iii

Contents

Acronyms v

Executive summary 1

Introduction 7

Overall review of progress 9

Better information for better results 10

Country Accountability Framework (CAF) 10

Recommendation 1: Civil Registration and Vital Statistics (CRVS) and Maternal Death Surveillance and Response (MDSR) 14

Recommendation 2: Health Indicators 20

Recommendation 3: eHealth and Innovation 25

Better tracking of resources for women’s and children’s health 28

Recommendation 4: Tracking Resources 28

Recommendation 5: Country Compacts 30

Recommendation 6: Reaching Women and Children 33

Better oversight of results and resources at national and global levels 35

Recommendation 7: National Oversight 35

1. Health reviews 35

2. Countdown to 2015: national Countdown events 38

3. Working with Parliaments 39

Recommendation 8: Transparency 41

1. Role of media networks 41

2. Working with civil society 43

Recommendation 9: Reporting Aid for Women’s and Children’s Health: OECD-DAC 44

Recommendation 10: Global Oversight 44

Implementing the iERG recommendations: IERG 46

Expenditure report 49

iv TRANSLATING RECOMMENDATIONS INTO ACTION

Risks and challenges 51

Looking forward 53

Conclusion 54

References 55

Acknowledgements 55

Annexes

Annex 1: Original Strategic Workplan with recommendations, indicators and targets 59

Annex 2: Financial expenditures by work area 63

Annex 3: Breakdown of catalytic funding across work areas 64

YEAR TWO: JULY 2012–MAY 2013 v

Acronyms

AIDS Acquired Immunodeficiency Syndrome

ALMA African Leaders Malaria Alliance

CAF Country Accountability Framework

CARMMA Campaign for Accelerated Reduction of Maternal Mortality in Africa

CDC Centers for Disease Control and Prevention

CHAI Clinton Health Access Initiative

CoIA Commission on Information and Accountability

CRVS Civil Registration and Vital Statistics

CRS Creditor Reporting Systems

CSO Civil Society Organization

DAC Development Assistance Committee (OECD)

DHIS 2.0 District Health Information Software version 2.0

DfID (UK) Department for International Development

DoV Decade of Vaccines

E4A Evidence for Action

EMRO Eastern Mediterranean Regional Office of WHO

eHealth Electronic health technology and systems

EU European Union

FP2020 Family Planning 2020

FIGO International Federation of Gynecology and Obstetrics

GAVI Global Alliance for Vaccines and Immunization

GOe WHO Global Observatory for eHealth

H4+ Health 4+ (UNFPA, UNICEF, WHO, World Bank, UNAIDS, UN WOMEN)

HAPT Health Account Production Tool

HFG Health Financing and Governance

HISP Health Information Systems Programme

HIV Human Immunodeficiency Virus

HMN Health Metrics Network

ICD International Classification of Disease

ICT Information and Communication Technology

IDSR Integrated Disease Surveillance and Response

iERG independent Expert Review Group

IHP+ International Health Partnership

ICM International Confederation of Midwives

IPA International Pediatric Association

IPPF International Planned Parenthood Federation

vi TRANSLATING RECOMMENDATIONS INTO ACTION

IPU Inter-Parliamentary Union

ITU International Telecommunication Union

LiST Lives Saved Tool

MDGs Millennium Development Goals

MDG 4 Millennium Development Goal 4: Reduce child mortality

MDG 5 Millennium Development Goal 5: Improve maternal health

MDR Maternal Death Review

MDSR Maternal Death Surveillance and Response

M&E Monitoring and Evaluation

mHealth Mobile health technology and systems

MNCH Maternal, Newborn and Child Health

MOU Memorandum of Understanding

NORAD Norwegian Agency for Development Cooperation

NGO Nongovernmental Organization

ODA Overseas Development Assistance

OECD Organisation for Economic Co-operation and Development

OHCHR Office of the United Nations High Commissioner for Human Rights

OpenMRS Open Medical Record System

PEPFAR (US) President’s Emergency Plan for AIDS Relief

PMNCH Partnership for Maternal, Newborn & Child Health

RMNCH Reproductive, Maternal, Newborn and Child Health

RMNCAH Reproductive, Maternal, Newborn, Child and Adolescent Health

SARA Service Availability and Readiness Assessment

SEARO South East Asia Regional Office of WHO

SHA 2011 System of Health Accounts 2011

SMGL Saving Mothers Giving Life initiative

SMS Short Message Service

SWAp Sector Wide Approach

TRACnet Treatment and Research AIDS Centre network

UN Women United Nations Entity for Gender Equality and the Empowerment of Women

UNAIDS Joint United Nations Programme on HIV/AIDS

UNECA United Nations Economic Commission for Africa

UNESCAP United Nations Economic and Social Commission for Asia and the Pacific

UNESCWA United Nations Economic and Social Commission for Western Asia

UNFPA United Nations Population Fund

UNGA United Nations General Assembly

UNICEF United Nations Children’s Fund

UNIWG United Nations Innovation Working Group

USAID United States Agency for International Development

WHA World Health Assembly

WHO World Health Organization

WPRO Western Pacific Regional Office of WHO

WP-STAT OECD Working Party on Statistics

YEAR TWO: JULY 2012–MAY 2013 1

Executive summary

1. It has been almost three years since September 2010 when the United Nations Secretary-General launched the Global Strategy for Women’s and Children’s Health – aiming to save 16 million lives by 2015 in the 75 countries where more than 95% of all maternal and child deaths take place. The Global Strategy called for a process to determine the best arrange-ments for global reporting, oversight and accountability for women’s and children’s health (Millennium Development Goals 4 and 5). This led to the formation of the Commission on Information and Accountability for Women’s and Children’s Health (CoIA), convened by President Kikwete of the United Republic of Tanzania and Prime Minister Harper of Canada. In May 2011, the CoIA published its 10 recommendations to strengthen accountability for women’s and children’s health. This report is the second progress update on the implemen-tation of the 10 recommendations.

2. There is no doubt that momentum has been created and progress achieved towards the CoIA recommendations. Table 1 provides a snapshot of the progress and a cumulative summary of results at 15 May 2013. The majority of the targets are on track; however, more rapid progress is needed against several recommendations, including: 2) Health Indicators; 3) eHealth and Innovation; 5) Country Compacts; 6) Reaching Women and Children; 7) National Oversight; and 8) Transparency.

Global-level progress3. In its report in 2012, the iERG made six recommendations of its own, two of which are

related to the Global Strategy for Women’s and Children’s Health and the global architecture.

4. The first iERG recommendation from 2012 was to strengthen global oversight. There has been significant global-level progress to implement this recommendation, namely work towards the development of an investment framework for women’s and children’s health, global governance mechanisms and greater attention to human rights.

5. The second iERG recommendation was to strengthen global governance. This is being implemented through the newly established Reproductive, Maternal, Newborn and Child Health (RMNCH) Steering Committee, which brings together high-level decision-makers from different initiatives under the Every Woman Every Child banner in order to align the international RMNCH response. Efforts are needed to bring in other partners under one governance structure that is underpinned by one accountability framework.

6. As identified by the iERG, more is also needed to maximize the combined country-level impact of the Commission on Life-Saving Commodities, the Global Vaccine Action Plan and Family Planning 2020, and to link all of these efforts.

7. Countdown to 2015 recently published its second global report on the trends in the 11 health indicators recommended by the CoIA. The Partnership for Maternal, Newborn & Child Health (PMNCH) is due to publish its 2013 report: Analysing Progress on Commitments to the Global Strategy for Women’s and Children’s Health.

2 TRANSLATING RECOMMENDATIONS INTO ACTION

Country-level progress8. In countries, it is clear that the accountability framework has gained traction as a guide to

implementing the 10 CoIA recommendations. To date, 58 of the 75 target countries have completed accountability frameworks or are in the process of completion. The Country Accountability Framework (CAF) process (described in Recommendation 1 below) has been instrumental in bringing together donors and country stakeholders and strengthening International Health Partnership (IHP+) processes. The CAF process has also generated high levels of demand from counties for resources and technical support to implement their country accountability frameworks.

9. By May 2013, 36 countries had received catalytic funds to create accountability frameworks. Countries are requested to submit progress reports twice each year on the implementation of framework activities. Virtually all other countries are in the process of raising awareness about the accountability framework in-country and finalizing their country accountability frameworks.

10. Assessments of civil registration and vital statistics systems (CRVS) have been complet-ed by 40 countries, of which 13 have completed the comprehensive assessment. There is strong political and partner support for this process, especially in regional bodies such as the United Nations Economic and Social Commission for Asia and the Pacific (UNESCAP) and the United Nations Economic Commission for Africa (UNECA), and through the global human rights bodies. Several countries are in the process of moving from assessment to implementation of plans, with the support and advocacy of multiple partners.

11. All 75 countries have been oriented to the new approach to maternal death surveillance and response (MDSR). With support from a range of partners, including Centers for Disease Control, Action Network, WHO, UNFPA, E4A, Saving Mothers Giving Life and FIGO, 53 countries have indicated they will prioritize actions to improve national, district and com-munity systems. Capacity building and sustained investment are among the priorities going forward.

12. Countries are taking steps to strengthen their health information systems, including sys-tems for annual routine reporting on health facilities. More than 20 countries are now using District Health Information Software (DHIS 2.0). This is an integrated approach that includes a web-based element that improves collection, transfer and analysis of facility data. Eleven countries have started to implement data quality mechanisms as part of efforts to improve transparency of data. They have conducted facility assessments to measure and monitor scale up of essential interventions and services for women and children. This includes moni-toring the 13 essential life-saving commodities identified by the United Nations Commission on Life-Saving Commodities for Women and Children. Global partners such as the Global Fund, GAVI, PEPFAR and the European Union are increasingly investing in national capaci-ties for monitoring of results and reviews, including health information systems, data quality and analytical capacity building for stronger health reviews and policy dialogue.

13. National eHealth strategies that include a focus on RMNCH have been developed in 27 countries. Sixteen mHealth solutions are being scaled up in 18 countries, in the context of Every Woman Every Child. Effective multistakeholder collaboration is critical to ensure scale up of eHealth applications and their integration into the health system.

14. Twenty-one countries are now tracking resources for women’s and children’s health, and an additional 23 are expected to have started work on health accounts by the end of 2013. This harmonized approach is based on the System of Health Accounts methodology (SHA 2011),1 with additional catalytic funding for this activity coming from the Global Fund. Continued technical assistance to institutionalize the approach is required.

1 http://www.who.int/nha/sha_revision/en/


15. To date, 40 countries report having signed a compact or equivalent agreement with develop-ment partners, and an additional six countries are in the process of developing such agree-ments. The accountability framework is an integral part of the Country Compact. With the renewed global momentum around IHP+, there is further opportunity and need to coordi-nate partner investments in, and work on, accountability processes at country level.

16. Fifty-three countries have reported they are conducting annual health sector reviews, to build a clearer picture of the gaps in their health-care provision and as the basis for nation-al accountability mechanisms. Broader participation of stakeholders in this process has increased transparency. However, much more needs to be done to engage the active par-ticipation of civil society and nongovernmental organizations (NGOs). Improvements in the quality of the analytical inputs would strengthen the evidence base for decision-making, policy dialogue and resource allocation.

17. Transparency is enhanced by better monitoring of results and tracking of resources, as described above. The benefits include better data on the 11 health indicators and better data and analyses to inform reviews of progress and performance. Dissemination of information is improved by the introduction of DHIS 2.0 and the launch of regional initiatives such as the African Health Observatory. Parliamentarians, civil society organizations (CSOs) and the media are all contributing to gradual improvements in review processes. Work with the Inter-Parliamentary Union (IPU) has already led to greater involvement of parliamentarians in women’s and children’s health issues. However, many countries lack strong CSOs and media that can play a role in regular reviews and accountability processes, which should lead to greater transparency and effective action.

18. In response to positive feedback on the first Countdown in-depth case study (on Niger’s success in reducing child mortality, published in the Lancet in September 2012), Countdown to 2015 is sponsoring four in-depth case studies in 2013. The countries include: Afghanistan/Pakistan as one case study, Ethiopia and Malawi. These countries have all indicated interest in disseminating their case study findings through a Country Countdown event, to be sched-uled towards the end of 2013 or in early 2014 after the case study results become available.

Funding Gap19. To date, US$ 24.2 million has been disbursed of the US$ 29.63 million made available to

date. The majority of these funds have gone to Country Accountability Frameworks. The sec-tion on expenditure provides a detailed report on financial progress to date.

20. There is an estimated funding gap of US$ 56 million for the projected implementation of the workplan. This includes a US$ 5 million gap for 2013, because the number of countries that are developing accountability frameworks exceeds expectation. Furthermore, resources are needed to continue to support countries in the second phase during 2014-2015. This is a significant risk, so efforts to measure and report on progress and better attract additional funding from donors will continue.

21. It should be further underscored that the overall funding required to support effective country implementation significantly exceeds the workplan funding estimate. Therefore, additional resources are required well in excess of the “catalytic” funding earmarked in the workplan budget. Country governments, partners and donors should be involved in mobiliz-ing resources and funding and developing investment plans for these on-going efforts.


Moving Forward22. The demand from countries for support and the momentum already achieved signal the

need to transition from the advocacy and planning stages to country action and results. This process will entail a need to:

1) engage a broader range of partners than is currently involved in implementing the work-plan at global and country levels;

2) better understand the support countries require to implement their accountability work; and

3) facilitate access to that support.

23. Now that countries have their frameworks, the priority is that countries receive the technical support they need from a wide set of partners. There is a need for a wider set of partners to support countries to achieve their CAF objectives. For some recommendations, countries and regions will have to build additional capacity. As a result, a cross-cutting capacity-build-ing strategy is needed to ensure that country requests can be serviced.

24. In future, there is a need to engage with a broader range of partners to scale up the account-ability effort. This is especially critical at country level, where a greater effort to mobilize resources is required to support country implementation.

25. In engaging with a broader set of partners, there is a need for civil society, government and other partners to work together in improving transparency. Social accountability at the com-munity level is an approach that can strengthen national oversight and accountability for implementation of recommendations and build investment by all stakeholders in strength-ening community systems for stronger accountability.


TABLE 1: SNAPSHOT OF PROGRESS TOWARDS THE COIA’S 10 RECOMMENDATIONS

Work Area Recommendation Target Result Statusa

Country Accountability Framework (CAFs)

Countries have plans for strengthening national accountability processes.

50 countries with CAFs by 2013.

58 CAFs completed or near completion.

36 CAFs funded.

1

Vital events and Maternal Death Surveillance and Response (MDSR)

By 2015, countries improve systems for registration of births, deaths and causes of death and health information systems.

50 countries with civil registration and vital statistics (CRVS) assessments and plans by 2015.

40 countries completed a rapid CRVS assessment; 8 countries have completed a comprehensive assessment.

50 countries making improvements in MDSR by 2015.

53 countries oriented to the revised MDSR approach.

2

Health Indicators

By 2012, countries using the same 11 indicators on RMNCH, disaggregated for gender and other equity considerations.

50 countries use and have accurate data on the core indicators.

75b countries reporting on core indicators (Countdown to 2015).

Global partners have streamlined reporting systems.

Global partners are streamlining reporting systems.

3

eHealth and Innovation

By 2015, countries integrating Information and Communication Technologies in national health information systems and health infrastructure.

By 2015, 50 countries developed and implementing national eHealth strategies.

27 countries developed and implementing national eHealth strategies linked to RMNCH.

4

Resource Tracking

By 2015, countries are tracking and reporting: 1) total health expenditure by financing source, per capita; and 2) total RMNCH expenditure by financing source, per capita.

By 2013, 50 countries have and use accurate data on the two indicators, as part of their monitoring and evaluation (M&E) systems.

21 countries tracking RMNCH expenditure. 50 planned by end of 2013.

5

Country Compactsc

By 2012, “compacts” in place between governments and development partners.

By 2015, 50 countries have formal agreements with donors.

40 countries have a compact or partnership agreement; 6 in process.

6

Reaching Women and Children

By 2015, governments have capacity to review health spending and relate spending to commitments, human rights, gender and equity goals and results.

Linked to Recommendations 2 and 4

Partnership for Maternal, Newborn & Child Health (PMNCH) tracks implementation of 293 commitments and spending.

7

National Oversight (Health Sector Reviews, Advocacy and Action)

By 2012, countries have transparent and inclusive national accountability mechanisms.

50 countries have regular national health sector review processes.

53 countries (where data are available) report having regular review mechanisms.

20 countries are engaging political leaders and financial decision-makers in health.

Parliaments from 50 countries engaged on RMNCH through implementation of IPU resolution.

a Status is based on completion of workplan activities.b Countdown to 2015 uses available data to produce country profiles. Most of the data for the CoIA indicators come from household surveys

(mostly from the USAID-supported demographic and health surveys and the UNICEF-supported multiple indicator cluster surveys). Although the Countdown to 2015 reports include all countries, not all countries have data available for all 11 indicators.

c The CoIA suggested a due date of 2012 for this recommendation. However, during the stakeholder meeting that developed the original strate-gic workplan for the implementation of recommendations, the date of 2015 was deemed more realistic.


Work Area Recommendation Target Result Status

7

Continued

50 countries have held a Countdown event.

10 countries are planning a Countdown event in 2013; four in-depth studies are being carried out.

8

Transparency

By 2013, stakeholders publicly sharing information on commitments, resources and results achieved annually, at both national and international levels.

50 countries with mechanisms for sharing and disseminating data.

Global partner databases for key 11 indicators publicly available through Countdown to 2015.

Global partners with databases on women’s and children’s health, and dissemination on core indicators.

20 countries with web-based facility reporting systems (DHIS 2.0).

9

Reporting Aid for Women’s and Children’s Health

By 2012, OECD-DAC to agree on improvements to Creditor Reporting System (CRS) to capture RMNCH health spending by development partners.

By 2012, development partners agree on the method.

Partners agreed on method (2012).

By 2013, OECD has developed guidance and instruction to support new method, and donors using new method.

OECD guidance in development so that RMNCH marker will be introduced in the CRS for 2014.

10

Global Oversight

2012–2015, an independent Expert Review Group (iERG) reporting to the United Nations Secretary-General on the results and resources related to the Global Strategy and progress on ColA recommendations.

Members appointed. Report submitted to Secretary-General during United Nations General Assembly in 2012.

Report due September 2012.

Legend

The target is on track. The result is achieved or is likely to be achieved before the deadline.

Progress is made to achieve the target, but a continued effort must be made to achieve it.

The target will be difficult to achieve, or the deadline has passed without the target being fully achieved.


Introduction

It is almost three years since the United Nations Secretary- General launched the Global Strategy for Women’s and Children’s Health (Global Strategy) in September 2010. This brought together countries and partners committed to achieving Millennium Development Goals (MDGs) 4 and 5 and saving 16 million lives by 2015. The Global Strategy focuses on 491 of the poorest countries and an additional 262 countries that are part of the Countdown to 2015. Together, these 75 coun-tries account for more than 95% of all maternal and child deaths.

The Commission on Information and Accountability (CoIA) was convened by the World Health Organization, and in 2011 delivered its report Keeping Promises, Measuring Results. This pre-sented 10 ambitious but practical recommendations to fast track monitoring and accountability for commitments for women’s and children’s health and achieve the goals in the Global Strategy (see Table 2). This report represents the second progress report to the iERG and assesses pro-gress towards the ColA’s 10 recommendations.

1 Afghanistan, Bangladesh, Benin, Burkina Faso, Burundi, Cambodia, Central African Republic, Chad, Comoros, Dem-ocratic Republic of Congo, Cote d’Ivoire, Eritrea, Ethiopia, The Gambia, Ghana, Guinea, Guinea-Bissau, Haiti, Kenya, Democratic Republic of Korea, Kyrgyz Republic, Lao PDR, Liberia, Madagascar, Malawi, Mali, Mauritania, Mozam-bique, Myanmar, Nepal, Niger, Nigeria, Pakistan, Papua New Guinea, Rwanda, Sao Tome and Principe, Senegal, Sierra Leone, Solomon Islands, Somalia, Tajikistan, Tanzania, Togo, Uganda, Uzbekistan, Vietnam, Yemen, Zambia and Zimbabwe.

2 Angola, Azerbaijan, Bolivia, Botswana, Brazil, Cameroon, China, Congo, Djibouti, Egypt, Equatorial Guinea, Gabon, Guatemala, India, Indonesia, Iraq, Lesotho, Mexico, Morocco, Peru, the Philippines, South Africa, South Sudan, Sudan, Swaziland and Turkmenistan.


TABLE 2: THE CoIA’S 10 RECOMMENDATIONS

Better information for better results1. Vital events: By 2015, all countries have taken significant steps to establish a system for registration of births, deaths and

causes of death, and have well-functioning health information systems that combine data from facilities, administrative sources and surveys.

2. Health indicators: By 2012, the same 11 indicators on reproductive, maternal, newborn and child health, disaggregated for gender and other equity considerations, are being used for the purpose of monitoring progress towards the goals of the Global Strategy.

3. Innovation: By 2015, all countries have integrated the use of Information and Communication Technologies in their national health information systems and health infrastructure.

Better tracking of resources 4. Resource tracking: By 2015, all 75 countries where 98% of maternal and child deaths take place are tracking and reporting,

at a minimum, two aggregate resource indicators: 1) total health expenditure by financing source, per capita; and 2) total reproductive, maternal, newborn and child health expenditure by financing source, per capita.

5. Country Compacts: By 2012, in order to facilitate resource tracking, “compacts” between country governments and all major development partners are in place that require reporting, based on a format to be agreed in each country, on externally funded expenditures and predictable commitments.

6. Reaching women and children: By 2015, all governments have the capacity to regularly review health spending (including spending on reproductive, maternal, newborn and child health) and to relate spending to commitments, human rights, gender and other equity goals and results.

7. National oversight: By 2012, all countries have established national accountability mechanisms that are transparent, that are inclusive of all stakeholders, and that recommend remedial action, as required.

8. Transparency: By 2013, all stakeholders are publicly sharing information on commitments, resources provided and results achieved annually, at both national and international levels.

9. Reporting aid for women’s and children’s health: By 2012, development partners request the OECD-DAC to agree on how to improve the Creditor Reporting System so that it can capture, in a timely manner, all reproductive, maternal, newborn and child health spending by development partners. In the interim, development partners and the OECD implement a simple method for reporting such expenditure.

10. Global oversight: Starting in 2012 and ending in 2015, an independent “Expert Review Group” is reporting regularly to the United Nations Secretary-General on the results and resources related to the Global Strategy and on progress in implementing this Commission’s recommendations.


Overall review of progress

Country-level progressThe second year of implementation towards the ColA’s 10 recommendations has demonstrated a shift to country-level action. Most countries now have Country Accountability Frameworks (CAFs) that are guiding the implementation of the 10 recommendations.

As highlighted in Table 1 above, recommendations where faster progress is needed include: 2) Health Indicators; 3) eHealth and Innovation; 5) Country Compacts; 6) Reaching Women and Children; 7) National Oversight; and 8) Transparency.

At the country level, it is clear that the accountability framework has gained traction in countries as well as with other initiatives under the Global Strategy for Women’s and Children’s Health. To date, 58 countries have CAFs completed or in the process of completion. Given this demand, it is expected that most of the remaining 17 countries will also develop CAFs and request cata-lytic funding. Twelve countries – Benin, Cameroon, Ethiopia, Lao Peoples Democratic Republic, Madagascar, Malawi, Mauritania, Nepal, Papua New Guinea, Solomon Islands, Tanzania and Togo – have submitted their first progress reports, which show that frameworks are in use. Other countries have more recently received catalytic funding and are just starting to implement CAFs, so we expect to see progress by the end of 2013.

Global-level progressGlobal-level progress has occurred around the implementation of the iERG’s 2012 recommenda-tions – namely to develop an investment framework for women’s and children’s health, global governance mechanisms and greater attention to human rights.

As recommended by the third stakeholder meeting for the Global Strategy,1 the 2013 account-ability workplan and budget were developed to reflect the iERG’s 2012 recommendations. For 2013, the workplan is focusing on the country level, and gaining a better understanding of which accountability approaches work well in each country. There is an increasing interest in health reviews and the revitalization of IHP+ and how it can help countries to improve women’s and children’s health, including promoting transparency at the country level.

US$ 24.2 million has been disbursed of the US$ 29.63 million made available to date, with the majority of funds going to CAFs. The section on expenditure provides a detailed report on finan-cial progress to date.

1 Third stakeholder meeting: taking stock of the progress and developing the strategy for 2013. November 2012, Ge-neva. Report available at: http://www.who.int/woman_child_accountability/news/third_stakeholder_meeting_GS_COIA_iERG_19_20_november_2012/en/


Better information for better results

Country Accountability Framework (CAF)

GoalDevelop country plans to augment accountability that are based on a rapid assessment and address priority areas for strengthening national accountability processes.

Target Progress May 2013

At least 50 countries have made commitments and completed CAFs by 2013.

71 self-assessments completed

581 national stakeholder consultations and CAFs developed

44 accountability frameworks completed (14 in progress)

36 CAFs funded

FIGURE 1: PROGRESS: COUNTRY ACCOUNTABILITY FRAMEWORK (CAF)

1 The 58 countries include: Afghanistan, Angola, Azerbaijan, Bangladesh, Benin, Bolivia (Plurinational State of), Bot-swana, Brazil, Burkina Faso, Cambodia, Cameroon, Central African Republic, Comoros, Congo, Democratic People’s Republic of Korea, Democratic Republic of the Congo, Djibouti, Egypt, Ethiopia, The Gambia, Ghana, Guatemala, Guinea, Haiti, Indonesia, Iraq, Kenya, Kyrgyzstan, Lao PDR, Lesotho, Liberia, Madagascar, Malawi, Mauritania, Mo-rocco, Myanmar, Nepal, Nigeria, Pakistan, Papua New Guinea, Peru, the Philippines, Rwanda, Senegal, Sierra Leone, Solomon Islands, Somalia, South Sudan, Sudan, Tajikistan, Togo, Uganda, United Republic of Tanzania, Uzbekistan, Vietnam, Yemen, Zambia and Zimbabwe.


Implementation progressOver the past year, greater efforts have been made to mobilize national stakeholders behind the accountability agenda. There are now 581 countries making commitments to strengthen account-ability through the development of country accountability frameworks. The process of convening national stakeholders for this work has triggered greater political momentum and awareness of the accountability framework. People from diverse technical and political backgrounds have been brought together – sometimes for the first time – and all are critical for improving women’s and children’s health. The case study below from Myanmar (Box 1) illustrates the range and impact of these activities. Of the 58 countries, 44 have completed and submitted CAFs and 36 have received catalytic funds and are starting to implement activities.

Box 1. Myanmar – national stakeholders meet to advance accountabilityHigh-level officials assembled in Naypyitaw, Myanmar, from 13 to 15 February 2013 to discuss the implications of the accountability framework for the country. The 115 delegates assessed the major gaps in their country’s RMNCH provision, and identified priority actions for implementing the framework and creating a CAF. Participants came from a wide range of disciplines and agencies, including the Ministry of Health and other related ministries. Representatives of local and international nongovernmental organizations, community-based organizations and United Nations agencies also attended the workshop.

Key elements of the Myanmar CAF:

• Training doctors in international classification of disease (ICD-10) birth and registration, and regular control of certification.

• Training 15 000 essential health service staff in using the routine reporting system for public health facilities and introducing a quality-assurance mechanism.

• Strengthening analytical reports for national reviews, including data-quality assessments.

• Formulating policy on notification of all maternal deaths. Forming committees for maternal and perinatal death-reviews at all levels. Developing a community system of maternal death surveillance and response using information and communications technology.

• Engaging government and development partners in the accountability process and working towards establishing a Country Compact.

• Establishing a coalition to conduct reviews, with participation of all stakeholders.

• Working with the media to improve transparency and accountability.

1 The 58 countries include: Afghanistan, Angola, Azerbaijan, Bangladesh, Benin, Bolivia (Plurinational State of), Bot-swana, Brazil, Burkina Faso, Cambodia, Cameroon, Central African Republic, Comoros, Congo, Democratic People’s Republic of Korea, Democratic Republic of the Congo, Djibouti, Egypt, Ethiopia, The Gambia, Ghana, Guatemala, Guinea, Haiti, Indonesia, Iraq, Kenya, Kyrgyzstan, Lao PDR, Lesotho, Liberia, Madagascar, Malawi, Mauritania, Mo-rocco, Myanmar, Nepal, Nigeria, Pakistan, Papua New Guinea, Peru, the Philippines, Rwanda, Senegal, Sierra Leone, Solomon Islands, Somalia, South Sudan, Sudan, Tajikistan, Togo, Uganda, United Republic of Tanzania, Uzbekistan, Vietnam, Yemen, Zambia and Zimbabwe.


Expenditure on CAFs■■ To date, a total of US$ 10.8 million has been disbursed to implement CAFs.

■■ An additional 14 CAF submissions for funding are currently under review.

■■ The CAFs vary from country to country in terms of prioritization of actions and allocation of catalytic funding. However, overall countries are prioritizing the strengthening of monitoring of results (24% of countries), maternal death surveillance and response (22%) and civil regis-tration and vital statistics (21%).

FIGURE 2: COUNTRY PRIORITIZATION OF CATALYTIC FUNDING, BY AREA OF WORK (COUNTRIES = 36)

PartnersAs well as generating greater political momentum, the CAF process has clearly facilitated bet-ter harmonization of investment efforts among partners and ministries. This contributes to the strengthening of country-review mechanisms and of processes to monitor results and resource.

Among global efforts, the Global Fund has mobilized an additional US$ 10 million in catalyt-ic funding to strengthen results monitoring and analytical capacity in about 20 countries. Key priorities include work to identify the cross-cutting components of monitoring and evaluation (M&E), which can be used to target mainstream disease and health-system issues. They include investing in underlying data systems – including vital statistical systems, health facility data and surveys – and strengthening analytical capacity to review programmes and the health sector.

GAVI is also investing heavily to strengthen in-country data-quality mechanisms. It is working with WHO and the Global Fund to assess and strengthen the capacity of countries to improve their systems for routine reporting on health facilities. The European Commission – through its European Union-policy dialogue project – is also contributing to important components of country frameworks, such as the strengthening of national review processes and mechanisms, and processes for policy dialogue.

USAID’s new evaluation policy has prioritized the evaluation of performance and impact, includ-ing data generation and evidence. It is conducting a series of summits relating to evidence and research gaps. The summit themes include: considering the best evidence on provision and use of maternal health services through financial incentives; the interface between the community and formal health system; and protecting vulnerable children. At country level, USAID contrib-utes significantly to M&E strengthening, particularly by supporting demographic health surveys.

CRVS 21%

MDSR 22%

eHealth 7%

Resource Tracking 11%

Reviews 6%

Advocacy 9%

Monitoring Results 24%

How are countries prioriEzing their catalyEc funds US$ 9. 2 million to date? (n= 36 countries)


Box 2. Tanzania – leadership in strengthening country-level accountability mechanisms

In 2011, President Kikwete of Tanzania co-chaired the United Nations Commission on Information and Accountability for Women’s and Children’s Health with Prime Minister Stephen Harper of Canada. Since then, Tanzania has continued to demonstrate its leadership by strengthening accountability within its own territory.

Tanzania and MDGs 4 and 5: Tanzania has significantly reduced its under-five and infant mortality rates. Under-five mortality declined from 147 per 1000 live births in 1999 to 81 per 1000 in 2010. Maternal mortality is also beginning to decline. A survey from 2010 indicates that the maternal mortality ratio was 454 per 100 000 live births. This is almost a 50% reduction from 1990. The MDG 5 target is a 75% reduction by 2015. With less than 1000 days remaining to reach the 2015 deadline, Tanzania has committed to continued investment and action to accelerate progress towards MDGs 4 and 5.

Tanzania’s Country Accountability Framework focuses on strengthening seven main areas: 1) monitoring of results; 2) tracking of resources; 3) civil registration and vital statistics systems; 4) maternal death review systems; 5) innovation; 6) information and communication technology; and 7) eHealth.

The Tanzanian Ministry of Health (MoH) is leading a broad-based consortium of partners to improve monitoring of results through the Monitoring and Evaluation Strengthening Initiative (MESI). This has created an electronic district health information system, which is being rolled out countrywide in 2013.

In order to strengthen Maternal Death Surveillance and Response, the MoH is revising maternal death review forms and guidance to incorporate response and action for maternal deaths.

Work is under way to revise the maternal newborn and child health component of the health management information system (HMIS). Capacity is being developed to roll out the revised and computerized tool, based on the DHIS 2.0 software. Data quality assessments are conducted for the data generated from the HMIS in the Pwani region and Zanzibar.

Tanzania is piloting a system for birth registration through the Registration Insolvency and Trusteeship Agency (RITA). It is rolling out a “catch-up” campaign to encourage parents to register the births of children under five who have not been registered. Proposals for a high-level steering committee have been developed, and planning has started to conduct a comprehensive assessment of national CRVS.

The government has introduced an electronic financial system (EPICOR), which tracks public expenditure at national, regional and district levels – an important step for institutionalizing the national health accounts. It is also drawing up a comprehensive record of partners working in the area of reproductive, maternal, newborn and child health. This includes a geographical focus and allocation of resources in order to avoid duplication of effort and maximize utilization of resources. The national health accounts process has been conducted twice. Most recently it included sub-accounts for child health and reproductive health.

The MoH conducts joint annual health sector reviews to ensure oversight. These engage all key stakeholders, including civil society organizations (CSOs) and the parliamentary standing committee on social services. For the purposes of transparency, health sector performance profile reports are made public. The process of conducting a mid-term review of the Health Sector Strategic Plan has also been initiated.

Parliamentarians continue to play an important role by advocating for resources for health and RMNCH services and holding the government accountable. Parliamentarians, in collaboration with CSOs, have formed parliamentary clubs on safe motherhood and family planning. These are intended to help fellow parliamentarians gain a better understanding of the issues, so they can more effectively hold the government accountable.

Despite good progress, Tanzania recognizes that MDGs 4 and 5 will not be fully achieved in 2015. They should therefore be addressed in the post-2015 agenda to ensure continued accountability for women’s and children’s health.

Risks and challengesThe accountability framework has gained a lot of traction at country level, with higher than expected demand from countries better committing to the CAF process and applying for catalytic funds. An additional 32 countries are expected to request catalytic funds by the end of 2013, and there is an urgent need for additional funding to support them.


Way forwardThe accountability agenda has given fresh impetus to the IHP+ principles of partner harmoni-zation and alignment. It provides a common framework that brings together various initiatives relating to information and accountability, as partners increasingly invest in a shared platform based on the CAF. However, all stakeholders need to build and strengthen this approach and engage a broader range of partners – particularly from civil society, the media and parliamentar-ians. Sustained coordination and monitoring of progress at country level are also needed.

Recommendation 1: Civil Registration and Vital Statistics (CRVS) and Maternal Death Surveillance and Response (MDSR)

GoalBy 2015, all countries have taken significant steps to establish a system for registration of births, deaths and causes of death, and have well-functioning health information systems that combine data from facilities, administrative sources and surveys.


At least 50 countries have completed an assessment, developed a plan, and have taken significant steps towards implementation by 2015 (> 20 by 2013)1

40 countries2 have completed a rapid assessment

8 countries have completed a comprehensive assessment and 4 are in progress

2 countries: (the Philippines and Egypt) have commenced implementation

Implementation progress■■ Demand from countries for support to improve CRVS is strong; 33 out of the 36 funded accountability frameworks prioritize CRVS.

■■ From July 2012 to April 2013, a further 10 countries (South Sudan, Afghanistan, Pakistan, Djibouti, Morocco, Somalia, Sudan, Iraq, Yemen and Solomon Islands) undertook rapid assessments of their CRVS systems, bringing the cumulative total to 40 countries.10

■■ In addition, a further eight countries have completed a comprehensive assessment of their CRVS systems (Burkina Faso, Egypt, Ethiopia, Djibouti, Iraq, Sudan, Yemen and Indonesia), and another four are finalizing their comprehensive assessments.

■■ The Philippines and Egypt have commenced implementation of CRVS strengthening based on their comprehensive assessments.

■■ In Asia, partners are currently supporting countries such as Cambodia, Lao People’s Democratic Republic, Papua New Guinea and Solomon Islands to undertake comprehensive CRVS assess-ments.

■■ The high level of demand from African countries for CRVS assessments is being addressed through UNECA, including the training of regional experts to support country CRVS assess-ments and planning. Many countries are likely to commence CRVS assessments in late 2013.

1 Significant steps include: rapid assessment of CRVS, comprehensive assessment of CRVS, a national CRVS improve-ment strategic plan, and action to improve CRVS resulting in improvements in birth and death counts and/or cause of death compilation.

2 Countries: Afghanistan, Azerbaijan, Bangladesh, Burkina Faso, Burundi, Cambodia, Cameroon, China, Comoros, Democratic Republic of Congo, Democratic Republic of Korea, Egypt, Ethiopia, Djibouti, Gabon, Ghana, Guinea-Bis-sau, Indonesia, Iraq, Kenya, Kyrgyzstan, Lao PDR, Madagascar, Malawi, Morocco, Pakistan, Papua New Guinea, the Philippines, Rwanda, Senegal, Sierra Leone, Solomon Islands, Somalia, South Sudan, Sudan, Uganda, Uzbekistan, Vietnam, Yemen and Zambia.


Critical role of regionsRegions around the world are making serious efforts to improve civil registration, acknowledg-ing that CRVS systems provide crucial legal identity data for individuals. They also provide vital statistics that produce essential health information on births, deaths and causes of death, and underpin knowledge of women’s and children’s health.

The interest generated by the work of the CoIA follow-up, combined with the financial contri-bution and support from the Health Metrics Network (HMN), has clearly helped to increase regional momentum to improve country CRVS. Highlights include:

■■ The United Nations Economic and Social Commission for Asia and the Pacific (UNESCAP) has established a major regional focus on CRVS strengthening. In December 2012, a high-level meeting on CRVS in the Asia-Pacific region was held in Bangkok. It endorsed the Draft Regional Strategic Plan for the Improvement of CRVS in Asia and the Pacific. The plan will be presented to a ministerial meeting in 2014. The Committee on Statistics consequently spon-sored a resolution to the Economic and Social Commission, which on 27 April 2013 passed a resolution entitled: Implementing the outcome of the High-level Meeting on the Improvement of Civil Registration and Vital Statistics in Asia and the Pacific. This resolution calls upon all United Nations agencies “…to increase their support to countries for the improvement of civil registration and vital statistics in the region”.

■■ The United Nations Economic Commission for Africa (UNECA) has in recent years led the CRVS strengthening activities in Africa, supported by WHO, Health Metrics Network and other partners. A training programme to prepare a pool of country experts to support country CRVS assessments and plans was held in Botswana in late May 2013. This is a critical activity to strengthen the small pool of CRVS technical assistance that is currently available. A similar programme was held in Bangkok for Asia in late 2012.

■■ The Eastern Mediterranean Regional Office of WHO (EMRO) has undertaken CRVS imple-mentation activities, with a high level of commitment from the WHO regional director and other regional partners. Two regional workshops and in-country workshops achieved progress on CRVS strengthening.

■■ The Health Metrics Network convened a global summit for partners in Bangkok in April 2013 to call for further global and regional action to strengthen CRVS. The summit gave countries an opportunity to showcase improvements in registration activity and innovation in CRVS sys-tems, and demonstrate how these have impacted on health and policy information. The sum-mit issued a call to action for all stakeholders to come together to make a global and regional commitment to country CRVS strengthening.

Box 3. Malawi – progress in strengthening birth registrationMalawi received catalytic funding in August 2012 and CRVS was prioritized. Birth registration in hospitals and health facilities in Malawi began in 2012 at Bwaila Hospital Maternity Wing, since when 14 000 newborns have been registered. Birth registration in hospitals has subsequently been rolled out to an additional 41 health centres. As many as 880 health personnel have been trained and are implementing birth registration in their respective maternity wings and health facilities.

Source: Malawi progress report, April 2013

Partner activityCRVS within countries is by its nature a multisectoral activity, so sectors within countries need to collaborate and coordinate their activity if the system is to be strengthened. A similar multipart-


ner approach is required at global level to sustain support and focus on CRVS strengthening. To this end, the most recent draft of the April 2013 Global CRVS Summit call to action notes that:

“[while] there has been progress in the development of CRVS systems around the world, driven by the actions of governments and regional initiatives in Africa, Asia and the Pacific, Latin America and the Middle East ... so far the global community has been unsuccessful in delivering sufficient coordinated and sustained support in the field of CRVS.”

However, there is now strong evidence that partner activity across regions is becoming more coordinated:

■■ There is active commitment across regions, supported by regional partners, to strengthen CRVS within countries. This is evidenced in the strong leadership and support received by UNESCAP and UNECA, and in the EMRO region.

■■ The regional networks are based on active participation by United Nations agencies, academic partners and NGOs in each region.

In addition, the involvement of the Health Metric Network has yielded results in some areas criti-cal to the future of CRVS globally:

■■ MOVE-IT – the HMN initiative that brought together partners to test and implement informa-tion technology innovations for CRVS – is concluding. A review and synthesis is underway and will be available in mid-2013.

■■ A systematic review of eHealth and mHealth innovations in CRVS has been completed in part-nership with the University of Oslo.

■■ A country costing study has been completed on the financing requirements of strengthening CRVS systems. Complementing the CRVS investment case, it provides a methodology coun-tries can use to estimate their investment needs for strengthening CRVS.

■■ A report on the state of the world’s CRVS systems has been commissioned by the Health Metrics Network and will be available in mid-2013.

Risks and challengesHMN has been the focal point for Recommendation 1 in supporting countries to assess and develop systems for registration of births, deaths and causes of death, but this has now ended. This presents both a coordination risk and a funding risk.

■■ HMN has funded all its work on CRVS in the past two years. With the cessation of HMN involvement, this important funding stream has closed and there will be a funding gap.

■■ HMN has also been playing the role of focal point for Recommendation 1. A new focal point has not yet been identified to coordinate CRVS work globally or to support activities already underway and maintain momentum for CRVS strengthening. This is a serious risk.

■■ WHO has set aside some funds from the accountability workplan for a technical officer to manage the transition of CRVS from HMN to a new focal point.

■■ The April 2013 Global Summit on CRVS called for the formation of a “light touch” global alli-ance for CRVS. However, funding and a home for the alliance have not yet been identified.

Successful CRVS system strengthening requires a sustained focus within countries. There is a risk with changes to HMN, and the 2015 deadline for MDGs, that focus on CRVS will dissipate.

■■ The April 2013 Global Summit draft calls for “… more strategic communication and advocacy about CRVS system improvement as a broad development and governance issue, with the aim of placing CRVS improvement at the forefront of the post-MDG and other partner agendas.”


■■ Past experiences in countries show the risk when attention for CRVS is fragmented between country agencies or between partners, resulting in unsustainable on-off results. Global action is required to maintain on-going engagement and advocacy for CRVS within countries and regions over the medium to long term.

Way forwardFollowing the Global Summit call to action, a multi-partner working group has been estab-lished, comprising members from UNICEF, WHO, UNESCAP, University of Melbourne, Plan International and CRVS experts, to consult immediately and propose a structure for a global alliance to strengthen CRVS systems. The CRVS technical officer in WHO is providing secretariat support to the CRVS working group.

To improve CRVS strengthening activities, it will be necessary to focus on synthesizing and uti-lizing data from CRVS systems more effectively, while at the same time building on the existing lessons in CRVS strengthening from countries and regions.

WHO will continue to support countries and regions within its resources and mandate, but it is critical to form a broader constituency of players to provide the multisectoral support and resources needed to accelerate improvement in country systems. UNICEF has expressed interest in supporting countries in birth registration and UNECA plans to support countries in the African region while UNESCAP plans to support countries in the Asia region.

Box 4. CRVS results in WHO Eastern Mediterranean RegionIn the last year, the WHO Eastern Mediterranean Region (EMR) has achieved remarkable CRVS strengthening results, having developed a plan of action and successfully implemented a stepwise approach to CRVS assessment in the region.

• From November 2012 to mid-January 2013, 22 of the 23 EMR countries completed either rapid or comprehensive CRVS assessments. The region’s 10 CoIA countries – Afghanistan, Pakistan, Djibouti, Egypt, Morocco, Somalia, South Sudan, Sudan, Yemen and Iraq – have now all completed rapid assessments of their CRVS systems.

• A CRVS intercountry workshop was conducted in Dubai in early 2013 for all CRVS stakeholders, including civil registration authorities, ministries of health and central statistical offices. Participants were trained in the conduct of CRVS comprehensive assessments and were introduced to other CRVS tools and resources for improving their CRVS systems.

• Subsequently, comprehensive CRVS assessments with the accompanying plan of action were completed in March/April 2013 for six countries: Yemen, Djibouti, Kuwait, Iraq, Oman and Sudan. Egypt’s comprehensive assessment had been completed in July 2012, so seven comprehensive assessments have now been completed in the region.

• WHO EMRO conducted a successful intercountry stakeholders meeting in Cairo from 7 to 8 May 2013, gaining country and stakeholder support for a regional CRVS plan. Key stakeholders include WHO, UNFPA, UNESCWA and UNHCR, all of whom have a pivotal role to play in support of the regional plan.

The region is also planning to sustain its support for CRVS strengthening in the medium term:

• There are 16 more comprehensive assessments required for the remaining EMR countries.

• The region will seek to support further CRVS capacity building, including coding and certification, and to follow up on implementation missions.

With HMN’s closure, this future work will require a resourcing strategy. EMR is closely engaged with other regional partners and with WHO about maintaining future regional CRVS activity.


Maternal Deaths Surveillance and Response (MDSR) and Quality of Care


At least 50 countries making improvements in MDSR 53 countries1 oriented to new MDSR approach

Implementation progress One of the major achievements around maternal mortality has been the creation of a global consensus on the need to move from maternal death reviews (MDR) to maternal deaths surveil-lance and response (MDSR). This highlights the significance of each maternal death and the need for identification, notification and review of deaths. It also paves the way for feasible and targeted recommendations to prevent maternal deaths, and for their implementation and subse-quent monitoring. MDSR aims to identify all maternal deaths, and makes each one a notifiable event, giving it greater visibility and importance. MDSR contributes to better information about the number of maternal deaths, places greater emphasis on response and action, and includes accountability for response.

This new approach, and how it differs from MDR, was introduced through regional workshops in all WHO regions in 2012. In all, 53 countries were oriented to the new approach. Additional oppor-tunities to promote the new approach were provided by the 2012 Congress of the International Federation of Gynecology and Obstetrics (FIGO), the 2013 Global Maternal Health Conference, and the 2013 Women Deliver Conference. Ministries of health, professional organizations and civil society organizations were able to share their experiences at these events.

MDSR has been highlighted as a priority activity by most countries, and some have received catalytic funding to initiate activities. Understandably, the timeframe for implementing MDSR and then observing resulting improvements in maternal survival is long.

Partners working in this area collaborated closely. The MDSR working group started with three partners but has since expanded membership to nine. Over the past year, the group’s Evidence for Action programme (funded by DFID) was supported by: Canadian Network for Maternal, Newborn and Child Health; International Confederation of Midwives; International Stillbirth Alliance; USAID; WHO; UNFPA; Centers for Disease Control, Atlanta; FIGO and Department for International Development (DfID). An MDSR implementation guide has been published by this group.

Country progress – Rwanda, India and Lao People’s Democratic RepublicRwanda has a system for maternal death notification in health facilities within 24 hours by SMS or internet. Most health facilities report on time and provide cause of death using ICD classifica-tions; eight out of 30 districts are implementing verbal autopsies. Recommendations resulting from maternal death reviews are discussed every month, while each semester a dissemination meeting is held for all stakeholders. An active coordination mechanism is in place, with Ministry of Health leadership and stakeholder engagement.

Most maternal deaths in the Indian state of Tamil Nadu occur in facilities, and the state requires notification of these deaths within 24 hours. Death reviews use a combination of social autopsy at community level and facility-based death reviews. The district collector chairs monthly death-review meetings, which family members of the deceased woman are invited to attend so informa-tion from the “client perspective” can be obtained. This is followed by a medical review of causes of death and recommendations. This process has increased awareness and accountability among

1 Angola, Azerbaijan, Bangladesh, Benin, Burkina Faso, Bolivia, Botswana, Burundi, Brazil, Cameroon, Central African Republic, Chad, Comoros, Congo, Democratic Republic of Congo, Ethiopia, Eritrea, Gabon, The Gambia, Ghana, Guatemala, Guinea, Haiti, Ivory Coast, India, Indonesia, Kenya, DPR Korea, Kyrgyzstan, Lesotho, Madagascar, Mau-ritania, Mexico, Mozambique, Nepal, Niger, Nigeria Peru, Rwanda, Senegal, Sao Tome and Principe, Sierra Leone, South Africa, Swaziland, Tanzania, Tajikistan, Togo, Turkmenistan, Uganda, Zambia and Zimbabwe.


all stakeholders, and the model has been recommended by the federal ministry for adoption in states that are currently using other methods.

In Lao People’s Democratic Republic, maternal death review training was conducted between September 2011 and December 2012. MDRs are now conducted in six of the country’s 17 prov-inces and the capital city, but need to be rolled out nationwide. The government is developing national-level capacity to oversee MDRs and act on their findings. The system consists of both facility-based and community-based reviews. For deaths in the community, initial notification is for all deaths in women of reproductive age, which leads to follow-up action by the district com-mittee. Facility reporting is limited to government facilities and to deaths known to be linked to pregnancy.

A decree for establishment of a National Maternal Death Review Committee in Lao People’s Democratic Republic is under development. To date only one aggregate report has been drafted, which indicates a need to address both demand- and supply-side factors. Traditional beliefs and lack of knowledge were found to constrain appropriate health-care seeking, while poor road con-ditions and lack of transport were found to significantly impair timely access to services. Services in health facilities were often poor in quality and/or lacking in essential supplies and equipment. It is too soon to assess the effective use of this information because the report has recently been drafted and the national-level capacity to respond is still being developed.

TABLE 3. MDSR PARTNERS IMPLEMENTING IN COUNTRIESEvidence for Action (E4A); WHO, H4+

In Ethiopia, partners are working with the Ethiopian Federal Ministry of Health to implement a national MDSR system to inform and guide its policies and programmes. With an estimated 85% of maternal deaths occurring in the community, the Ethiopia MDSR system will primarily use health workers to capture data.

Action Network (hosted by the Campaign on Accelerated Reduction of Maternal Mortality in Africa – CARMMA)

In Sierra Leone, an Action Network under the office of the First Lady will convene policy-makers, managers, clinicians and civil society representatives committed to an effective system of maternal death reviews. This network (a sub-network of the global network) will facilitate the sharing of national evidence and advocate for resource mobilization, mentorship, training and other quality-of-care improvements.

Evidence for Action (E4A) In Nigeria, E4A is currently gathering evidence on the extent to which MDRs (or equivalent) are currently implemented and whether findings are used. E4A is also gathering lessons learned about common challenges and constraints.

The Saving Mothers Giving Life initiative (SMGL – a partnership of the US Government, Government of Norway, Merck, ACOG and Every Mother Counts)

SMGL plans to support the development of MDSRs in Uganda and Zambia as part of its commitment to the development of sustainable systems for the measurement of maternal health outcomes. Centers for Disease Control and Prevention (CDC) will provide technical assistance for the implementation of MDSRs in the SMGL districts in these countries.

The International Federation of Gynecology and Obstetrics (FIGO)

FIGO has been working with eight countries through the FIGO Leadership in Obstetrics and Gynaecology for Impact and Change (LOGIC) initiative in maternal and newborn health. The programme plans to strengthen MDSR through FIGO member associations in India, Nepal, Mozambique, Cameroon, Nigeria, Uganda, Kenya and Ethiopia.

Centers for Disease Control and Prevention (CDC)

CDC is providing technical assistance to the Government of Haiti on the implementation of MDSR in two developmental corridors of the country. These areas will serve as a pilot for the rest of the country.

Centers for Disease Control and Prevention

CDC is working with the Integrated Disease Surveillance and Response (IDSR) group at WHO/AFRO to implement components of MDSR that are potentially linked to IDSR in appropriate countries.

World Health Organization South East Asia Regional Office (SEARO)

SEARO completed a study on the implementation of MDR in five countries: India, Indonesia, Myanmar, Nepal and Sri Lanka.

World Health Organization Western Pacific Regional Office (WPRO)

WPRO is reviewing existing MDR work and working towards strengthening MDSR in Lao PDR, Cambodia, Vietnam, Papua New Guinea and the Philippines.


Risks and challengesThere is insufficient capacity to support countries to implement MDSR at scale, so capacity building is a priority.

Successful MDSR implementation is challenging and requires strong leadership and commit-ment. Implementers must be willing to share information and have the ability to recognize prob-lems, identify and implement appropriate solutions and follow up on the recommended actions. It requires carefully thought out strategies and takes a long time to establish. Success in reducing maternal deaths is usually only seen after a few years, so lack of immediate results should not discourage implementers.

Resources for MDSR are limited. In such circumstances it is advisable to start small, focusing on deaths in facilities before moving to community-based studies.

Way forwardIncreasing coverage of interventions without ensuring quality of care is a major concern. MDSR is one approach that addresses quality of care in maternal health and perinatal health. Reviews of why mothers die or nearly died (near miss) provide opportunities for quality assessment and improvement. Periodic assessments of service readiness in facilities and frequent monitoring of tracer indicators of quality of care in maternal and perinatal health provide additional informa-tion on quality of care. The MDSR working group is working towards promoting harmonized approaches for quality assessment and improvement activities.

Stronger collaboration within countries between ministries of health, professional organizations and CSOs can contribute to a better understanding of the data and causes of death. It can help partners to address quality of care in health services, and to develop specific solutions for end-ing preventable maternal mortality. PMNCH is a vehicle to bring in a wide range of civil society partners and help all stakeholders become more familiar with the new MDSR approach.

Build capacity for standardized training in MDSR at the regional level. A regional pool of experts will be trained in the standard tool and guidelines for conducting MDSR in mid-2013 and these experts will support countries in MDSR implementation.

Recommendation 2: Health Indicators

GoalBy 2012, the same 11 indicators on reproductive, maternal, newborn and child health, disaggre-gated for gender and other equity considerations, are being used for the purpose of monitoring progress towards the goals of the Global Strategy.


At least 50 countries use and have up-to-date accurate data on the core indicators, disaggregated, as part of their M&E systems

Global partners have streamlined reporting systems

At least 50 countries have timely and accurate data from core coverage indicators to inform annual reviews, with appropriate data-quality controls (20 by 2013)

75 priority countries have data on indicators

GAVI, Global Fund and UNAIDS streamlining reporting system


FIGURE 3: COUNTDOWN 2013 ACCOUNTABILITY REPORT

Educated women are more likely to give birth with a skilled attendantSkilled attendant at birth, by maternal education, Countdown countries with recent data

1 The new Countdown report has been produced by a global collaboration of academics and health professionals from Johns Hopkins University, Aga Khan University, Federal University of Pelotas in Brazil, Harvard University, London School of Hygiene and Tropical Medicine, UNICEF, the World Health Organization, UNFPA, Family Care Interna-tional, Save the Children and other institutions from around the world. The secretariat of the Countdown to 2015 initiative is based at the Partnership for Maternal, Newborn & Child Health.

Implementation progressThe Countdown to 2015 report, Accountability for Maternal, Newborn and Child Survival,1 was launched in May 2013. It provides an update on progress on the 11 core indicators selected by the CoIA in its 75 target countries.


The report indicates “remarkable progress” in some of the world’s poorest countries in cutting mortality rates among mothers and young children by 50% or more. However, greater effort is required to improve the coverage of life-saving interventions like antibiotic treatment of pneumo-nia and postnatal care for women and newborns. Rwanda, Botswana and Cambodia have made notable progress in reducing mortality since 2000, each ranking in the top five for rate of reduc-tion among the 75 countries studied in this report. This success is particularly notable in light of much slower progress in the 1990s, when in some cases mortality rates rose due to conflict and instability and/or high HIV prevalence rates. More than half of these countries have reduced both maternal and child mortality at a faster rate since 2000 than they did during the decade from 1990 to 2000.

This year’s report includes data from an additional 22 surveys, as compared with the 2012 report. At present, household surveys are the main source of data for nine of the 11 indicators. For many of the core coverage indicators, the optimal scenario for reporting is a combination of survey data with quality data from health facilities. Ideally, annual data should be split by district to allow sub-national analysis within health sector reviews and for planning and programmatic purposes.

In this regard, efforts are being stepped up in many countries to improve the availability and quality of reporting on core indicators, based on facility reporting systems. The University of Oslo – with support from the HISP (Health Information Systems Programme) network,1 and financial support from NORAD, the Global Fund and PEPFAR – is work-ing to improve the collection, analysis and acces-sibility of annual data on core indicators through the introduction of DHIS 2.0 software. This is a simple, open-source, web-based system, designed to improve routine reporting. So far, 11 countries are implementing DHIS 2.0 to improve their rou-tine reporting systems, including Bangladesh, The Gambia, Ghana, Guinea Bissau, Kenya, Liberia, Rwanda, Sierra Leone, Solomon Islands, Uganda and Zanzibar. A further 10 countries are either piloting or planning to roll out the system, includ-ing Colombia, Democratic Republic of Congo, India, Malawi, Mozambique, Nigeria, Senegal, Tajikistan, Tanzania and Zimbabwe.

As part of this work, and based on the WHO data-quality report card methodology, a number of countries have taken steps to strengthen the assessment of data collected from health facilities. Regular independent verification through a facility record review adds objectivity and aids devel-opment of annual data-quality reports.

The report card methodology is currently being integrated into the DHIS 2.0 system, in order to allow for the production of automated annual reports.

Countries are also making progress in measuring and monitoring the scale up of interventions and services to save more women and children. As a direct result of the accountability work-shops – and with support from WHO – GAVI and the Global Fund have implemented facility assessments of service readiness and data verification, while many more partners are planning to implement them. Standard indicators are used to assess and monitor the availability of medi-

In DRC, the accountability process has given a real boost to harmonization of partner support to strengthening the national health facility reporting system (SNIS). For years this faced major challenges and constraints relating to fragmentation of data collection efforts across programmes, provinces and partner projects. With financial and technical support from the Global Fund, DfID, WHO and other in-country partners, efforts are currently underway to revise and update the core indicators, including the RMNCH indicators. An electronic district reporting system, based on DHIS 2.0 and including ICT infrastructure, is being rolled out to a large number of zones de santé in the country.

1 HISP includes: WHO, University of Oslo, University of Pretoria, University of Western Cape, Centers for Disease Control and Prevention, UNAIDS, European Union, Rhino, and International Center for AIDS Care and Treatment Programs.


cines, commodities, basic equipment and skilled health workers. They also assess the capacity or readiness of facilities to provide key essential services for women and children, including family planning, basic and comprehensive care and newborn, child and adolescent health services. The assessment includes collection of data on the availability of the 13 essential life-saving medicines and commodities, and will serve as an important country-led system for monitoring the avail-ability of commodities in health facilities.

Countries that are establishing regular systems to assess service readiness in health facilities and data verification mechanisms include Benin, Burkina Faso, Cambodia, Democratic Republic of Congo, Ethiopia, Kenya, Mauritania, Sierra Leone, Tanzania, Togo, Uganda and Zambia.

WHO, in close collaboration with global and country partners, is intensively supporting the prep-aration of analytical reports of health system progress and performance. This is part of prepara-tions for the mid-term reviews in Uganda and Tanzania during the third quarter of 2013. The aim is significantly to improve the quality of the analysis – with a strong focus on RMNCH, equity analyses and efficiency of results and resources.

Risks and challengesSustained long-term investment in a country’s health information system is required to strength-en country capacity to monitor results. This is particularly so to improve the routine annual reporting systems, and national analytical capacity to conduct high-quality evidenced-based reviews of progress and performance. To accelerate progress, stronger partner collaboration and harmonization of activities and investment will be required, along with scale up and institution-alization of health data collection and analysis, and its dissemination at country level.

Way forwardTo strengthen and scale up national analytical capacity for programme and health sector reviews, WHO is working with the Global Fund and GAVI to establish a pool of prequalified consult-ants and service providers. Preference is given to national and regional institutes that could be contracted on a country-by-country and/or regional basis to support analytical work, includ-ing assessments of service readiness and data quality. WHO will assist in the coordination of the technical service work at country level through its WHO country offices. It will ensure that the activities are carried out in close collaboration with ministries of health, and are coordinated and harmonized with the country planning processes and other related activities.


Box 5. Sierra Leone – monitoring scale up of interventions and services to save women and children

In recent years, Sierra Leone has shown rapid progress in the implementation of key health initiatives. Following the National Health Sector Strategic Plan 2010–2015, the country launched the Free Health Care Initiative (FHCI) in April 2010 to provide free health services to pregnant women, breastfeeding mothers and children under the age of five years. FHCI offers antenatal, postnatal and delivery services, diagnostic services and treatment, and basic and comprehensive emergency obstetric and newborn care. The Basic Package of Essential Health Services for Sierra Leone was also launched in 2010. This outlines priority health interventions to reduce mortality rates, particularly for women and children, and specifies the essential health services to be provided at each level of health service delivery.

The Ministry of Health and Sanitation conducted a service availability and readiness assessment (SARA) of health facilities in advance of the annual health summit in 2011, and again in 2012. This informed the annual health sector review and the planning process. In particular, SARA was intended to fill key data gaps

in service delivery and readiness and to monitor progress in the roll out of the Basic Package of Essential Health Services nationwide.

Readiness to provide delivery services, 2011/2012

Percentage of facilities with tracer items (N/2011=188, N/2012=92)

The graph shows the percentage availability of tracer items in facilities that offered delivery care in 2012 as compared with 2011. Almost no facilities had all 19 tracer items required to offer basic delivery services. Availability of antibiotic eye ointment increased substantially, from 28% in 2011 to 76% in 2012. In addition, availability of suction apparatus, intravenous solution with infusion set, partograph and guidelines for IMPAC also increased from 2011. Availability of injectable uterotonic appears to have decreased from 76% to 53%. On average, facilities had 12 of the 19 items in 2012, for an overall readiness score of 65 out of 100 – a slight increase on 56 out of 100 in 2011.

Percentage of facilities that have essential life-saving medicines and commodities in stock and valid – Sierra Leone, SARA 2012.

The graph shows the percentage availability of the 13 essential life-saving commodities in facilities that offer RMNCH services. There was higher availability of child-health medicines compared to commodities for family planning.


Recommendation 3: eHealth and Innovation

GoalBy 2015, all countries have integrated the use of Information and Communication Technologies (ICTs) in their national health information systems and health infrastructure.


By 2015, at least 50 countries have developed and are implementing national eHealth strategies, including specifics on how this benefits information and accountability for women’s and children’s health

27 countries1 (with available data) have a national eHealth strategy and plan in place

Implementation progressThe integration of information and communication technologies (ICT) in health systems remains a goal to be achieved by many countries. Experience has shown that harnessing ICT for health requires planning at the national level to make the best use of existing capacity, while providing a solid foundation for investment and innovation. To date, 27 countries have developed national eHealth strategies. Most recently six countries (China, Fiji, Malaysia, Mongolia, the Philippines and Vietnam) have completed their national eHealth strategies, with an RMNCH component.

A joint approach developed by WHO and the International Telecommunication Union (ITU) has set out the core components of a national eHealth strategy and a method for its development. The two organizations have begun a series of workshops to improve capacity and respond to country requests for assistance in this cross-cutting area.

WHO and the ITU have also joined forces to augment the knowledge base on eHealth. This includes establishing a new database of eHealth projects in support of women’s and children’s health. The eHealth projects repository will be of particular value to anyone who wants to learn from the experiences of others, such as programme managers working on eHealth projects, policy-makers and donors.

A technical and evidence review group on mHealth has also been established to support work on building and synthesizing evidence about the role of mHealth innovations for improving RMNCH.

The WHO Global Observatory for eHealth (GOe) is documenting the use of eHealth for the ben-efit of women’s and children’s health. It is the first systematic assessment of its kind, providing much-needed insight into the progress of Member States in meeting the ColA’s 10 recommenda-tions on eHealth and informing actions going forward. The survey is being conducted in the 75 CoIA countries and will produce two reports for the ColA:

■■ A comprehensive analysis and report including case studies from selected countries, jointly produced by WHO and the ITU;

■■ An atlas of all CoIA countries detailing each eHealth country profile as it relates to women’s and children’s health.

In a related initiative to support Every Woman Every Child, the mHealth Alliance (in partnership with the Innovation Working Group and the Norwegian Agency for Development Cooperation) has supported a mechanism that provides catalytic funding to scale up promising mHealth pro-grammes that aim to improve RMNCH outcomes. WHO provides research support to the grant-ees in: Pakistan, India, Malawi, Tanzania, South Africa, Democratic Republic of Congo, Kenya, Mali, Nigeria, Ghana, Cameroon and Senegal. The project (with the mHealth Alliance and United

1 Azerbaijan, Botswana, Burundi, China, DPRK, DRC, Egypt, Ethiopia, Ghana, India, Indonesia, Iraq, Kenya, Kyr-gyzstan, Lao People’s Democratic Republic, Madagascar, Mali, Morocco, Papua New Guinea, Peru, the Philippines, Sudan, Turkmenistan, Uzbekistan, Vietnam, Zambia and Zimbabwe.


Nations Innovation Working Group) is giving technical and research support to 16 RMNCH mHealth solutions (in 18 countries) to help with scale up and institutionalization.

Progress on eHealth and innovation – Bangladesh, Rwanda and MalawiExamples from two countries show the kind of progress that can be made using ICT in health services and information systems:

Bangladesh has adopted an eHealth Standardization and Interoperability Framework as a foun-dation for the exchange of data across multiple platforms. Mobile phones have been given to each district and sub-district hospital to use for reporting selected RMNCH data elements on a periodic basis. In addition, eHealth/mHealth projects providing pregnancy care advice through SMS have made significant progress. Services based on GPS technology are also available to help people locate health-care service providers.

In Rwanda TRACnet (Treatment and Research AIDS Centre Network) is used for the collection of HIV data. It employs timely interactive voice response technology to gather information through mobile phones and the web. In addition, the use of mobile phones to support community-health workers is an essential component of the national eHealth Strategy. In a few facilities, clinical data and aggregate data have been integrated by using the Open Medical Record System (OpenMRS) and DHIS 2.0. This makes it possible to obtain aggregate data of RMNCH indicators directly from electronic medical records.

In Malawi an assessment of eReadiness has been conducted in all districts. Nineteen comput-ers have been provided (one in each district) for DHIS 2.0 data entry and an mHealth task force has been established as a subgroup of the M&E technical working group. Data collection for an eHealth situation analysis has been completed, and the data analysis is in process. It is also planned to conduct a situation analysis focusing especially on mHealth. The mHealth group is working with telecom providers to upgrade the infrastructure for electronic communication.

Partners: International Telecommunication Union (ITU) and the Innovation Working GroupITU and WHO are the key partners in implementing Recommendation 3. In particular, they are involved in making available essential training materials in seven languages for eHealth capac-ity building. They are working to appraise the status of eHealth in countries and are compiling a report on the use of ICT for women’s and children’s health (scheduled for July 2013) . Together, they aim to provide the critical link between the ministries of health and ICT providers in coun-tries.

The Innovation Working Group (IWG) is an alliance led by the government of Norway and Johnson & Johnson and has a membership of over 60 partners representing governments, civil society, the private sector, the United Nations and international organizations. It aims to find “innovative ways to deliver enabling environments and solutions to scale up successful pilots to further progress towards MDGs 4 and 5”. Hosted at PMNCH, the IWG opened an Asia chapter on 28 May 2013.

Risks and challengesIn its 2012 report, the iERG recommended increased uptake of eHealth and mHealth. eHeath initiatives have been criticized for often getting no further than pilot projects and not being taken up to scale. In many cases this has been caused by a lack of funds, problems with connectivity or the absence of empirical evidence to support their value. However, some eHealth projects have proved they can be scaled up and work as an integrated part of the health system. To have significant value, future eHealth projects must be able to do the same.

Multisectoral collaboration for eHealth development is a new process for many countries. As a result, the health and ICT sectors in those countries might lack the necessary expertise and


awareness of eHealth, and the efficient channels of communication and collaboration needed to progress. The challenge of multisectoral collaboration is compounded by the need to assess the many small-scale pilot projects launched by donors, agencies and the private sector, and scale up and integrate those that work. Finally, it is essential to make sure that specific RMNCH concerns are addressed in national eHealth strategies.

Way forwardeHealth projects that aim to improve the health of women and children often establish a com-munication channel between different parts of the health system. Such channels may be used both to improve RMNCH and to strengthen the health system as a whole. They can also be used to strengthen the CRVS system through registration of births, deaths and causes of death. The RapidSMS system in Uganda is an example of how the medium used for eHealth can also be used for registration of births. Experiences from Uganda, Senegal and Brazil show that involving community workers from different sectors and mobile technologies can help countries move closer to 100% registration of births.1

Effective implementation of Recommendation 3 requires better coordination of external inputs and technical teams. This is an ongoing challenge due to time and resource constraints.

Two WHO regional workshops (SEARO and EMRO) were scheduled for June and July 2013, and three additional regional workshops are being scheduled in Africa and Europe. These are designed to share positive examples of eHealth for women’s and children’s health, and to build capacity in eHealth planning. They will also support and accelerate the development of national eHealth strategies in the regions. In addition, 10 national eHealth strategy workshops are planned before the end of 2013.

Data and systems interoperability, which enables the seamless exchange of data between two or more systems or components, is considered essential to achieve the full potential of eHealth applications. To ensure interoperability at all levels, including medical devices, WHO is establish-ing a web-enabled knowledge gateway of health data standards and interoperability. In addition, a WHO Handbook on eHealth Standardization and Interoperability is being developed, to assist countries to fully integrate the use of ICTs in their national health information systems and health infrastructure.

1 http://unicefinnovation.org/challenges/increasing-child-birth-registration


Better tracking of resources for women’s and children’s health

Recommendation 4: Tracking Resources

GoalBy 2015, countries are tracking and reporting: 1) total health expenditure by financing source, per capita; and 2) total RMNCH expenditure by financing source, per capita.


By 2013, 50 countries use and have accurate data on the two indicators, as part of their M&E systems

21 countriesa tracking reproductive, maternal, newborn and child health (RMNCH) expenditure

6 countries (Benin, Burkina Faso, Cameroon, Burundi, Rwanda and Tajikistan) have started work on health accounts and will have results by June

By the end of 2013, 15 additional countries have started work on health accounts: Comoros, DRC, Ethiopia, Gabon, The Gambia, Ghana, Liberia, Malawi, Niger, the Philippines, Tanzania, Togo, Uganda, Vietnam and Zambia

a As per May 2013; countries might change.

Implementation progress■■ The Health Account Production Tool (HAPT) includes automatic reports for RMNCH and other disease-specific expenditure flows;

■■ A template has been created for IT developments to facilitate yearly automatic collection and importation of expenditure data into the HAPT.

PartnersSeveral partners are involved in conducting the work on tracking resources: countries’ health account teams; WHO (providing technical oversight); and several global initiatives – the Global Fund to Fight AIDS, Tuberculosis and Malaria (the Global Fund); Decade of Vaccines (DoV); Family Planning 2020 (FP2020); USAID’s Health Financing and Governance (HFG); and The Clinton Health Access Initiative (CHAI). Most stakeholders have agreed to use the System of Health Accounts as a framework.1 This is an internationally recognized methodology for compre-hensive tracking of spending in the health sector, and is the standard platform approach to take forward in countries.

An example of how partners can assist with harmonized tracking of resources is the memo-randum of understanding (MOU) signed between the Global Fund and WHO for countries approaching renewal of Global Fund grants. The MoU incorporates counterpart financing track-ing in the agenda for accountability resource tracking. This partnership with the Global Fund has catalysed additional funds to support resource tracking in countries.

1 http://www.oecd.org/els/health-systems/asystemofhealthaccounts2011.htm


Harmonizing resource tracking of health expenditure at the global and country levelsResource tracking enhances accountability mechanisms and practices, and helps to highlight whether resources are sufficient and being used efficiently, equitably and sustainably. By applying a standard platform for tracking, this work has helped to harmonize the tracking of health expen-ditures. It has also increased awareness at the country level that evidence-based policy-making for women’s and children’s health can be strengthened by asking questions to learn more about the expenditure flows for RMNCH. For example, who pays and what type of RMNCH services are provided in the country?

The approach is currently being implemented in 25 countries, and aims to set up and institution-alize a harmonized country platform for collecting data. Wherever possible, the downloading and mapping of data will be automated. This will help ensure that expenditures can be reported annually with greater technical rigour, and will ease the demands on national staff.

There are several advantages of this approach:

1. It is more technically rigorous because there is a standard way to allocate expenditures by diseases and type of interventions.

2. It will ensure that estimates of current and capital health expenditure are internally consist-ent.

3. The health expenditure data produced is robust and timely for the development and assess-ment of health sector strategic plans. This is facilitated by HAPT, which guides users through the entire production process, thereby reducing the need for technical assistance and increasing local capacity for production of health accounts.

4. The use of a consistent platform that integrates data collection of RMNCH expenditures with the existing health information system ensures comparability of country data over time.

5. It will reduce duplication of effort and make reporting more regular and frequent. It should also reduce errors, allowing the process to focus more on the reporting of data and its use for national planning purposes.

6. Annual production of comprehensive health expenditure data enables the process to become a natural component of the annual cycle of the health information system, and of health strategy and planning.

Risks and challengesAll resource-tracking initiatives and activities should be kept under the same umbrella. Many stakeholders want to track resources flows in their own areas. To ensure consistency, SHA 2011 – the global standard for health expenditure reporting, with its distributional table by beneficiary (disease) – should be the organizing technical framework for reporting. Resource flow tracking on the ground should be harmonized for more technical rigour and to ease the demands on national staff.

Ensure adequate funding for resource-tracking activities in the country. Country frameworks appear to have allocated limited or no funding for resource-tracking activities. Although intended to be catalytic in nature, the amounts being allocated are barely adequate for that purpose. In response, WHO and partners are attempting to persuade other resource-tracking initiatives to pool their funds into one effort in each country, and this has now been agreed upon with the Global Fund. More negotiations with other partners are needed on the tracking of resources for family planning and immunization.

Ensure access to all relevant data from stakeholders in country. In particular, private-sector data is needed to ensure accurate estimates of the total extent of health expenditures.


Way forwardTechnical assistance should be continued with the aim of institutionalizing a harmonized coun-try platform for collecting expenditure data that includes RMNCH, and to build capacity at the country level.

Accountability processes in countries should be improved by creating health account teams in ministries of health, and by partnering with parliamentarians and CSOs to use RMNCH expendi-ture data for policy planning.

In order to facilitate resource tracking for health in countries, stakeholders should continue to work closely with IHP+ to ensure that Country Compacts address transparent reporting of expen-ditures by external partners.

Work is starting with civil society partners to improve country resource tracking (see the section on working with civil society).

Recommendation 5: Country Compacts

GoalBy 2012, in order to facilitate resource tracking, “compacts” between country governments and all major development partners are in place that require reporting, based on a format to be agreed in each country, on externally funded expenditures and predictable commitments.

Target * Progress May 2013

By 2015, at least 50 countries have formal agreements with donors

31 countries are signatories to the IHP+

40 countries have a compact or equivalent partnership agreement.

6 additional countries are in the process of developing such agreements: Cote d’Ivoire, Djibouti, The Gambia, Guinea, Haiti and Sudan

Implementation progressIHP+ principles maintain that all partners involved in RMNCH should hold each other to account on progress made against commitments to improve health-aid effectiveness and results. In some countries, mutual accountability is being increased through more-inclusive health-policy dialogue and through joint health sector reviews and monitoring of Country Compacts. IHP+ has also developed a scorecard that provides a simple, one-page overview of an agency’s or country’s progress towards implementing its IHP+ commitments (see Figure 4 for the example of Ethiopia below).

Of the 75 countries, 40 are reported to have a compact or equivalent partnership agreement, with an additional 6 in the process of development.

■■ Updates of existing agreements planned in 5 countries: Cambodia, Kenya, Mozambique; Solomon Islands; Vietnam;

■■ Expected product 2012/2013: 7 additional countries have compacts. Status: 6 additional countries have developed compacts since Jan 2012: Burkina Faso, Burundi, Mauritania, Togo, Senegal, Zambia

■■ Expected product 2013/2014 indicative: 7 additional countries have completed compacts / equivalent

■■ No compact expected: Countries where external aid is a very low share of total health expendi-ture, as these are very unlikely to benefit from developing compacts. Examples include China; Indonesia.


FIGURE 4: ETHIOPIA COUNTRY SCORECARD 2012

Information from countries that are not members of IHP+ is more limited. Only two of these countries, Ghana and Kyrgyzstan, have reported the existence of common management agree-ments with donors. Tajikistan has had a letter of intent for the Sector-Wide Approach (SWAp) since 2008 (see Table 4).

Many IHP+ signatories benefit from small catalytic grants to support coordination and harmoni-zation processes in countries, of which a small proportion is used for developing and implement-ing the Country Compacts.

There are two observable trends in the recent compacts: 1) non-state actors/CSOs are com-monly signing compacts, and 2) more compacts now include specific indicators for tracking commitments. The CoIA also recommended two types of commitments: 1) transparent reporting

TABLE 4: COUNTRIES WITH COMPACTS/PARTNERSHIP AGREEMENTS

Compact/partnership agreement Countries TotalSigned before January 2012 Angola, Bangladesh, Benin, Brazil, Burkina Faso, Burundi, Cambodia,

Chad,a Comoros, Democratic Republic of Congo,b Egypt, Eritrea, Ethiopia, Ghana, Guatemala, Iraq, Kenya, Kyrgyzstan, Lao, Mali, Malawi, Mauritania, Mexico, Mozambique, Nepal, Niger, Nigeria, Papua New Guinea,c

Philippines, Rwanda, Senegal, Sierra Leone, Solomon Islands, Swaziland,d Tanzania, Togo, Uganda, Vietnam, Yemen, and Zambia

40

New compact planned or to be revised in 2013

In preparation: Botswana****, Cote d’Ivoire, The Gambia, Haiti, and Sudan, Zimbabwe

6

Planned: Djibouti, Guinea, Somalia

a pre-compact; b memo d’entente; c SWAp; d letter of intent for SWAp


of expenditures by external partners, and 2) the use of existing national platforms to promote mutual accountability.

All compacts include some text on external budget transparency – generally that partners agree to use country financial systems where possible and to disburse in a predictable manner. Just over half of compacts outline a system to review commitments made, mostly through joint annu-al reviews. However, the commitments of development partners are rarely reviewed at these events, although some countries are beginning to do so.

A paper commissioned by IHP+ reviewed the experiences of nine countries: Benin, Ethiopia, Mali, Mauritania, Nepal, Nigeria, Sierra Leone, Togo and Uganda.1 The overall conclusion was that compacts are worth the effort, as they improve the quality of dialogue and aid coordination (see Box 6 for additional highlights).

Additional information about transparent reporting of expenditures by external partners comes from the 2012 IHP+ Results Annual Performance Report.2 One quantitative indicator assessed by this survey was the extent to which development partners recorded a large proportion of their aid on budget. The report shows that eight of the 17 development partners participating in the survey have met the target of 85% of their aid recorded on budget.

1 Developing a country compact. What does it take and what are the gains? IHP+, December 2012. http://www.internationalhealthpartnership.net/fileadmin/uploads/ihp/Documents/Upcoming_events/Developing%20a%20compact.Dec2012.pdf

2 IHP+Results 2012 Annual Performance report. http://ihpresults.net/download-reports/

Box 6. Highlights from the 2012 review of Country Compacts1. Countries have improved the quality of dialogue and partnership for aid coordination. The compacts

have enabled countries to better understand the external support received, and to align it to national plans.

2. The key value of compacts is as an overarching guide that sets the direction of travel and high-level objectives for the partnership to improve the efficient use of health resources.

3. Achievement of compact commitments requires ongoing work to develop and implement specific tools and instruments, such as joint financing agreements, joint reporting and harmonized technical assistance.

4. Compacts can bring international legitimacy and moral strength to efforts to coordinate national aid.

5. Commitments and indicators for improved partnership and aid effectiveness that are agreed in compacts are not routinely reported on as the basis for mutual accountability.

PartnersCompacts are signed by a mix of development partners, which varies by country. On the govern-ment side, the ministries of finance and health commonly sign, and sometimes other govern-ment bodies – for example local government in Sierra Leone.

International development partner signatories commonly include the United Nations agencies, development banks and major bilateral donors in the country concerned. Non-state/civil society actors also increasingly sign compacts. Non-resident agencies such as GAVI and the Global Fund do not sign but may provide explicit letters of support.

At the recent World Health Assembly, the US Government became a signatory of the IHP+. This is intended to facilitate countries’ work in establishing, implementing and enforcing compacts.


Risks and challengesThere are three principal risks. The first is that compact preparation and negotiation of commit-ments is hurried and “formulaic”, so local ownership and locally appropriate content is compro-mised, i.e. there is no real support for the commitments the compact contains. A second related risk is that once a compact has been signed it is put on a shelf and forgotten. A third risk is that commitments are overly ambitious, insufficiently concrete and lack targets, so progress can-not be measured. The challenge is to mitigate these risks by ensuring that a compact genuinely reflects the signing country’s interests and ambitions, contains realistic commitments and has effective local champions.

Way forwardThe 2012 review found that – notwithstanding some weaknesses – Country Compacts are seen as useful instruments to improve understanding of external aid received, and its alignment with national priorities. However, they are not magic bullets for improved accountability. They do tend to become more explicit and inclusive over time, as country’s accumulate experience of negotiat-ing meaningful partnership agreements. Looking forward, the existing trend to include indicators to track commitments needs to be encouraged, as does the inclusion of explicit reviews of pro-gress against compact commitments in joint annual reviews. In Nairobi in 2012, IHP+ signatories agreed to progressively embed selected indicators of health development effectiveness in their own national monitoring systems, which is an important step forward.

Recommendation 6: Reaching Women and Children

GoalBy 2015, all governments have the capacity to regularly review health spending (including spend-ing on reproductive, maternal, newborn and child health) and to relate spending to commit-ments, human rights, gender and other equity goals and results.

Targeta Progress May 2013

Development partners will commit to strengthen capacity related to accountability processes in an additional 10 countries each year, prioritizing those with the highest burden of women’s and children’s ill health

PMNCH tracks implementation of 293 commitments and spending

a Progress towards this recommendation and target is linked to Recommendations 2 (health indicators), 4 (resource tracking) and 7 (health reviews).

Implementation progressJoint annual reviews (fully described under Recommendation 7), provide the platform for coun-tries to regularly review health spending against the goals articulated in national health plans. Although this is being done in most countries, there is room for improvement in country pro-cesses. For example, the work on health reviews is focused on demonstrating more clearly how spending affects health outcomes.

In 2011 and 2012, PMNCH produced reports that analysed global progress on commitments to advance the Global Strategy.1 The 2013 version of this report, due to be launched in September 2013, will broaden the analysis of the types of commitments made to advance the Global Strategy and further examine the extent of their implementation and progress. The report will analyse the implementation of financial commitments and policy, research and advocacy commitments. It will also consider commitments for delivering services and products and strengthening health systems and examine four thematic areas: adolescent health; family planning; newborn health; and advocacy (see box on PMNCH report under Recommendation 8).

1 The PMNCH 2013 Report: Analysing Progress on Commitments to the Global Strategy for Women’s and Children’s Health. Geneva, PMNCH.


Moving forwardCountries are in the implementation phase for Country Accountability Frameworks, and several have submitted a progress report. To build on this, a selected group of countries will receive support to conduct comprehensive studies of how health spending relates to health outcomes in joint annual reviews.


Better oversight of results and resources at national and global levels

Recommendation 7: National Oversight

GoalBy 2012, all countries have established national accountability mechanisms that are transparent, that are inclusive of all stakeholders, and that recommend remedial action, as required.


At least 50 countries have regular national health sector review processes that meet basic criteria including broad stakeholder participation

At least 50 countries have held at least one Countdown event

At least 20 countries have made progress in engaging political leaders and financial decision-makers in health

53 countries (where data available) have conducted an annual health sector review in the last year or have reported having a regular review mechanism in their Country Accountability Framework

No country has conducted a national Countdown event

Parliamentarians from 50 countries have been engaged

1. Health reviews

Implementation progressFifty-seven countries have undertaken, or are planning to undertake, an annual health sector review or mid-term review of their national health sector strategic plan in 2012–2013 – or have reported having a regular review mechanism in their Country Accountability Framework. Of these, 53 have already conducted a review: Afghanistan, Angola, Bangladesh, Benin, Bolivia, Brazil, Burkina Faso, Burundi, Cambodia, Cameroon, Chad, China, Comoros, Democratic People’s Republic of Korea, Democratic Republic of the Congo, Equatorial Guinea, Eritrea, Ethiopia, The Gambia, Ghana, Guinea, India, Indonesia, Iraq, Kenya, Kyrgyzstan, Lao People’s Democratic Republic, Lesotho, Liberia, Madagascar, Malawi, Mali, Mauritania, Morocco, Mozambique, Nepal, Nigeria, Papua New Guinea, Peru, the Philippines, Rwanda, Senegal, Sierra Leone, Solomon Islands, South Africa, Sudan, Tajikistan, Tanzania, Togo, Uganda, Vietnam, Zambia and Zimbabwe. An additional four countries are planning one this year: Côte d’Ivoire, Gabon, Guinea Bissau and Niger.1

Twenty-five countries prioritized health reviews through their country accountability frame-works. Catalytic funds made available to countries to implement their Country Accountability Frameworks should prove valuable for countries that have not previously undertaken reviews, or to support country work to improve the quality of reviews.

IHP+ commissioned a study of nine countries’ experiences while conducting joint annual reviews of the health sector. This served as background paper for a structured discussion at the 4th IHP+

1 Sources: Country Planning Cycle database, country accountability frameworks, reporting from countries and techni-cal agencies. It is likely that this figure is under-reported as data collection of review processes at the global level remains a challenge.


Country Health Teams Meeting in December 2012,1 which involved 29 countries.2 The study high-lighted that countries find joint annual reviews an important mechanism to review implementa-tion and identify areas for improvement. Lessons from this study (highlighted in Box 7 below) are being taken into consideration to support countries in review processes.

1 http://www.internationalhealthpartnership.net/fileadmin/uploads/ihp/Documents/Upcoming_events/JAR%20Final%20Report%20Feb2013.pdf

2 Benin, Burkina Faso, Burundi, Cambodia, Cameroon, Cape Verde, Chad, Côte d’Ivoire, Democratic Republic of Con-go, Djibouti, El Salvador, Ethiopia, The Gambia, Guinea, Kenya, Mali, Mauritania, Mozambique, Nepal, Niger, Nige-ria, Pakistan, Senegal, Sierra Leone, Sudan, Togo, Uganda, Vietnam and Zambia.

3 http://www.internationalhealthpartnership.net/fileadmin/uploads/ihp/Documents/Upcoming_events/JAR%20Final%20Report%20Feb2013.pdf

Box 7. Highlights from the IHP+ study of the joint annual review (JAR) process• All actors surveyed considered JARs useful.

• A strength of JARs is that they are tailor-made and country-specific: no one size fits all.

• Despite country differences, all JARs share common features: they are part of the annual M&E cycle; in general they review implementation of the annual programme of work; they tend to become more inclusive over time.

• Added value

— JARs tend to strengthen policy dialogue, alignment, accountability, implementation of the sector plan and internal resource allocation. But a JAR is only one factor in this.

— JARs have a potential to improve plans, mobilize additional resources and promote joint accountability.

— JARs are less recognized for improving harmonization, setting new targets and reducing transaction costs.

• Factors that determine a successful JAR include: strong government leadership; a high degree of local ownership; meaningful and wide participation of all stakeholders; a constructive climate of opinion and an open policy dialogue.

• Main challenges are: ensuring that data is timely, of good quality and properly validated; integrating JAR recommendations into operational plans; finding ways to balance greater participation with good policy dialogue.

Country examplesCountries are also strengthening their review practices, for example by using a bottom-up approach to engage key constituents. This is happening in Bangladesh, Democratic Republic of Congo, Ghana, Mozambique, Papua New Guinea and Uganda, where district visits are conduct-ed as part of annual reviews. Malawi plans to conduct a national MNCH programme review to feed into the annual sector review. Furthermore, in some countries, such as Kyrgyzstan, annual reviews have helped to increase the health sector budget.3

PartnersThe composition of partners in JARs varies depending on the country context. For example, Mozambique has a well-defined review process involving the Ministry of Health, development partners and NGOs. Cambodia invites stakeholders from outside the health sector such as the ministries of education, women s affairs, planning, interior, economy & finance, social affairs, labour and defence.

In countries where participation is broad – such as the Democratic Republic of Congo, Ghana and Uganda – annual reviews can better promote mutual accountability. Ideally, all potential or active partners should participate in review mechanisms. These will include those active in the


health sector (public, private not-for-profit and for-profit, professional associations, NGOs and consumers) as well as outside of the sector (e.g. other ministries, national financing agencies, academia, civil society, and parliament) and development partners.

At the global level, partners are recognizing the value of review processes. Donors, including GAVI are increasingly participating in annual reviews to monitor progress of grants in lieu of requiring countries to complete separate agency-specific reporting procedures. For example, in Nepal GAVI has signed the Joint Financing Agreement and has been using the JAR as the basis to renew its funding to the country.

Risks and challengesThe quality of country reviews varies widely. As highlighted above, one of the main challenges remains the timely availability of good-quality, properly validated data. Countries also need the capacity to perform strategic analysis of data and draw lessons for decision-making.

Another challenge that persists is the collection and dissemination of the review outcomes and reports.

Way forwardWHO and other technical agencies are working in countries to improve data collection, valida-tion and analyses and to better link the data to decision-making. Capacity-building efforts include supporting countries in generating relevant information through facility and survey data and equity analyses to enable evidence-based policy-making.

In addition, efforts are being made to improve an online repository of relevant country docu-ments.1 This should further facilitate national planning processes and better integration of RMNCH with other programmes. It should also increase transparency by allowing key materials to be disseminated more easily via the web.

Box 8. Case studies: Nepal, Mozambique and Burundi – examples of the growing investment

Nepal held its third JAR in January 2013a with a broad set of partners. These included: 13 external development partners; nine government sectors; and 27 civil society and professional organizations e.g. the Rotary Club and Image TV, and 18 hospitals, academics and other service providers . The JAR assessed the performance of the national health strategic plan against its stated objectives, using demographic health surveys. Partners critically reviewed areas where progress is lagging and identified action to improve performance. They agreed to have the Aide Memoire produced for the JAR classified as a public document to improve transparency. The Ministry of Health will take the results of the JAR into consideration for the next review.

Mozambique has a bottom-up, participatory approach to JARs, based on input from provincial reviews. The government and partners conduct joint field visits in advance of the JAR and use data policy development and key milestone events to inform their work. The government and partners agree on a set of indicators, including key maternal and child health targets, to monitor progress.

Burundi has organized JARs since 2007. The Ministry of Health and national and international partners conduct joint field visits, which are key for fostering accountability. The current Minister of Health has sought support from WHO to strengthen the quality of both data collection and informed decision-making at the country level. This should lead to improved commitment from stakeholders to achieving universal health coverage.a http://www.internationalhealthpartnership.net/fileadmin/uploads/ihp/Documents/IHP__news/Signed%20Aide%20Memoire%20

2013.pdf

1 http://www.internationalhealthpartnership.net/en/tools/country-planning-database/


The revitalization of the IHP+ approach will serve to contribute to this recommendation. The “Seven Behaviours”1 identified by partners to accelerate progress on MDGs, include joint assess-ments and monitoring of implementation and results based on one common monitoring, evalu-ation and accountability platform.

2. Countdown to 2015: national Countdown events

Country Countdown is an important strategy to improve monitoring and follow-up action for accountability at the country level. A Country Countdown initiative can help partners to work together and measure progress more effectively as part of the national planning process. It can also help them identify ways to increase coverage and improve outcomes for women’s and chil-dren’s health.

Although no countries carried out a national Countdown event during 2012 and early 2013, some countries have started the Country Countdown process. These include Burkina Faso, Kenya, Malawi, Pakistan, Rwanda, Sierra Leone, Tanzania, Uganda, India (Uttar Pradesh) and Zambia. Burkina Faso, Kenya, Pakistan, Tanzania and Zambia have all formed national teams to lead the Country Countdown process. There are formal expressions of interest from governments through the accountability framework or through a letter sent from the Ministry of Health directly to Countdown.

Countdown is also supporting four in-depth case studies in 2013: Afghanistan/Pakistan as one case study, Ethiopia, Malawi and Peru. All of these countries have indicated interest in dissemi-nating their case study findings through a Country Countdown event. We anticipate these events will take place towards the end of 2013 or early in 2014, after the case study results become avail-able.

A case study on maternal mortality declines was initiated in Bangladesh in late 2012. Final results were expected in mid- 2013, and the case study team is now exploring options for disseminating the findings through a Country Countdown event.

The results of the first Countdown in-depth case study on Niger’s success in reducing child mor-tality was published in The Lancet in September 2012, and included a comment from the Minister of Health. The case study showed that Niger was able to reduce child mortality by implementing government policies that supported universal access, nutrition programmes and provision of free health care for pregnant women and children.

Civil society alliances for MNCH have advocated Country Countdown processes with the support of PMNCH. A manager was recruited at the Countdown Secretariat to strengthen internal and external communication streams. The Countdown Secretariat is hoping to recruit another person to help with coordinating the country-level work. This would include other initiatives aimed at country-level engagement, such as A Promise Renewed and the African Leaders Malaria Alliance (ALMA) scorecard initiative.

Countdown has disseminated a comprehensive Country Countdown toolkit,2 with guidance on all the steps involved in carrying out a Country Countdown. It includes an implementation check-list, national, sub-national and equity profiles for the 75 priority countries, and a customized PowerPoint presentation for each of the 75. A two-page brief summarizing the benefits of con-ducting a Country Countdown was disseminated at international meetings in 2012.

Risks and challenges Countdown has experienced delays in setting up Country Countdown events due to the time required to generate government interest and identify lead organizations in country to coordinate

1 http://www.internationalhealthpartnership.net/en/news-events/ihp-news/article/seven-behaviours-how-develop-ment-partners-can-change-for-the-better-325359/

2 Available at www.countdown2015mnch.org


the process. To address this, Countdown formed a country- level working group to roll out the Country Countdown in the 75 target countries, and to organize technical support for in-country teams. A focal person within the global Countdown team is designated to work closely with each in-country Countdown team to answer any questions and provide support throughout the Countdown process. Internal communication about country-level activities has been improved by making sure that the co-chairs of the country-level working group are represented on the Countdown scientific and leadership groups.

Way forwardCountdown hosted an all-day orientation workshop on the Country Countdown and in-depth case studies on 31 May 2013 in Kuala Lumpur. It was attended by more than 100 participants from 25 countries and there was great enthusiasm for moving forward with Country Countdowns.

Efforts are also underway to establish a consortium across Countdown, A Promise Renewed, ALMA and other ColA follow-up exercises. This would help to ensure that country engagement is harmonized, stimulates action and encourages the use of evidence for decision-making. Representatives of each of these initiatives will discuss opportunities for collaboration during the World Health Assembly (WHA) and Women Deliver events.

Countdown planned a capacity-building workshop at the Federal University of Pelotas in Brazil from 17 to 21 June 2013. The aim was to help develop the skills that in-country partners need to carry out the quantitative analyses required for the in-depth case studies. The workshop focused specifically on strengthening capacity to analyse coverage and equity data, and to undertake analyses using the Lives Saved Tool (LiST). A companion workshop to strengthen capacity in analysis of health systems and policies is being developed for later in 2013.

3. Working with parliaments to engage political leaders and financial decision-makers

Implementation progressParliamentarians are vital to the allocation of resources and to legislation and oversight. These elements have been a major part of the accountability work conducted in partnership by PMNCH, the Inter-Parliamentary Union and the Pan-African Parliament. The collaboration resulted in the IPU resolution on the role of parliaments in securing women’s and children’s health, unani-mously adopted in 2012 by all 162 Member Parliaments. The resolution calls on parliamentarians to ensure political will, concerted action by parliaments and collaboration among parliaments to contribute to improved health outcomes for women and children.

The IPU has co-hosted and participated in several strategic events, such as the Commission on the Status of Women, the World Health Assembly, Women Deliver and the Pan-African Parliament African Women Parliamentarians Conference. These events raise awareness of the issue, position it in the context of the IPU resolution and promote action among parliamentar-ians for improved women’s and children’s health.

The IPU has developed an accountability mechanism to support implementation of its resolu-tion. This includes the establishment of a focal point for global parliamentary accountability for implementing RMNCH commitments made under the auspices of the IPU. The IPU used the mechanism to develop its first annual accountability report1 on the implementation of its resolu-tion, presented to the IPU Governing Council during the IPU Assembly in Quito in March 2013. The report surveyed parliamentarians serving on committees for finance, health and the MDGs about their work on implementing key aspects of the resolution. The main findings from the survey indicate:

1 The report is available at: http://www.who.int/entity/woman_child_accountability/news/Report_of_IPU_MNCH_Event_at_128th_Assembly.pdf


■■ There is significant support for RMNCH by parliamentarians, and particularly around determi-nants of health, gender equality and health workforce strengthening.

■■ Political will and awareness around women’s and children’s health needs to be maintained and extended. There is considerable scope for the IPU to secure greater visibility and momen-tum for parliamentary efforts.

■■ Parliamentarian should use the oversight and accountability tools at their disposal to moni-tor budgetary processes and commitments made to the Global Strategy and to fulfil financial commitments to health initiatives.

At the country level, there is increasing demand to work with parliamentarians as a result of emerging results. In Uganda, during the last budget negotiations, the National Assembly took steps to block the budget until the government agreed to allocate more funds to health. An out-come of this is that steps have since been taken to increase the number of trained health profes-sionals in rural health centres, so that most centres now have two doctors.

Mauritania started implementation of its CAF in November 2012 and has established a com-mission of parliamentarians working on RMNCH. On 7 March 2013, it hosted a workshop for parliamentarians and senators on information and accountability for women’s and children’s health. This was part of a process of building a network of parliamentarians to promote RMNCH.

Risks and challengesThe accountability mechanism developed by the IPU to track implementation of the IPU resolu-tion is based on self-reporting by Member Parliaments. Within these limitations, the IPU will continue to pursue options for making its accountability mechanism more rigorous.

Way forwardThe IPU accountability report will be followed at the 129th Assembly of the IPU in Geneva in October 2013 by the launch of a new handbook for parliamentarians on women’s and children’s health. It will be presented at a special event, which will also highlight the latest Countdown find-ings and the plans for the new investment framework for women’s and children’s health.

Box 9. Parliamentarians strengthening accountability for women’s and children’s health

• The Pan-African Parliament’s annual African Women Parliamentarians Conference attracted 80 women parliamentarians from 40 countries, who committed to ensuring accountability for maternal, newborn and child health at the regional and national levels. The resolutions taken were subsequently ratified by a sitting of the Pan-African Parliament.

• The Parliament of Kenya is assessing in what ways its legislation promotes or hinders maternal, newborn and child health. The IPU will provide further support to the incoming parliament to implement some of the priorities identified, such as a comprehensive Maternal Health Bill.

• Parliamentarians of the East African Legislative Assembly set out to use the IPU resolution to revitalize their work to improve maternal and child health in the five EALA member countries: Burundi, Kenya, Rwanda, Uganda and Tanzania.


Recommendation 8: Transparency1

GoalBy 2013, all stakeholders are publicly sharing information on commitments, resources provided and results achieved annually, at both national and international levels.


At least 50 countries have effective data-sharing and dissemination mechanisms

Global partners have up-to-date databases on women’s and children’s health and effective dissemination of country-level and global data on the core indicators

In 2011, government and partners should further clarify their announced financial commitments (up to US$ 40 billion) to the Global Strategy for Women’s and Children’s Health to enable these commitments to be tracked at global and country levels

Global partner databases for key 11 indicators publicly available through Countdown to 2015 accountability report

11 countries have RMNCH civil society alliances to improve joint accountability efforts

National reviews are mechanism for data sharing and dissemination (Recommendation 7)

PMNCH report reviews the implementation of stakeholder commitments to the Global Strategy

Implementation progressThe ColA recognized the need for greater transparency between citizens, programme imple-menters, development partners, academic and research institutions and civil society and the media. Transparency includes several components, and gradual progress is being made on each.

Better monitoring of results and tracking of resources, described above, provide the necessary data for transparency. The benefits include better data on the 11 health indicators and better data and analyses to inform reviews of progress and performance. Dissemination of information is improved by the introduction of DHIS 2.0 in over 20 countries and the launch of regional initia-tives such as the African Health Observatory.

Parliamentarians, CSOs and the media are all contributing to gradual improvements in review processes. Work with the IPU has already led to greater involvement of parliamentarians in wom-en’s and children’s health issues. However, many countries lack strong CSOs and media that can play a role in regular reviews and accountability processes, which should lead to greater transpar-ency and effective action

Globally, the annual PMMCH exercise of tracking commitments made in response to the Global Strategy is an important tool for improving transparency. It provides useful baseline data on the financial, policy and programme commitments towards the Global Strategy.

1. Role of media networks for greater transparency

PMNCH continues to invest heavily in media advocacy. In 2012, 10 global media campaigns on women’s and children’s health were produced, reaching an estimated 1.5 billion media consum-ers across all platforms. These include TV, radio, online and, increasingly, partner-based social media. However, much more can be done to partner with media for greater accountability and scrutiny, including of budgets and investments. The media – including mobile and online net-works – is a huge, under-used and rapidly growing resource for accountability and public partici-pation.

Globally, PMNCH has coordinated several major partner-based press campaigns. These included: the results of its 2012 PMNCH report on the implementation of Global Strategy Commitments; papers in The Lancet on the Countdown’s work on equity, official development assistance (ODA)

1 Transparency recommendation is linked to: data transparency, which includes strengthening reviews, Countdown data, monitoring resources, civil society and working with parliaments.


and the Niger case study; increasing action on preterm birth (World Prematurity Day, Nov 2012); and drawing attention to the prevalence of early marriage and associated health and education risks (Commission on the Status of Women/International Women’s Day, March 2013). The media campaign reach figures (reports: Hoffman & Hoffman) were estimated at 150 million media consumers (Countdown/PMNCH report stories), 1.4 billion (preterm birth/World Prematurity Day, including 80 million Twitter impressions, as per TweetReach reports), and 400 million (early marriage).

Way forwardWorking with the Africa MNCH Coalition and One World Media, PMNCH is developing a strat-egy to encourage key media institutions in Africa to provide more in-depth coverage of RMNCH. This should increase the media’s capacity to report on it effectively, and help to improve account-ability for results and resources.

The strategy seeks to build the capacity of media owners, editors, correspondents and reporters on the key RMNCH issues. It aims to create a sense of ownership among the media, and raise awareness of the need for accountability on RMNCH and related development issues. The media strategy will use regional and country-level mapping exercises to identify key media bodies, jour-nalist associations and unions and health journalists in Africa. It will aim to promote increased

Box 10. The PMNCH 2013 Report – Analysing Progress on Commitments to the Global Strategy for Women’s and Children’s Health

PMNCH produced reports in 2011 and 2012 that analysed the progress in implementing commitments to advance the Global Strategy. The 2012 report analysed responses from 181 respondents to produce the first evidence-based estimate of financial commitments to the Global Strategy – estimated at up to US$ 20 billion in new and additional resources. It also offered an updated content analysis of the commitments made. The report was released at an accountability event, organized by PMNCH with Countdown to 2015 and the iERG, during the United Nations General Assembly.

The 2013 PMNCH report will provide an update on the progress in implementing commitments to the Global Strategy, as well as the remaining gaps and challenges.

More specifically, its objectives are to:

• Document new commitments made to the Global Strategy since April 2012.

• Analyse the extent to which each of the commitments made since the launch of the Global Strategy has been implemented (adding to the existing analysis in the 2011 and 2012 PMNCH reports) across the commitment categories of: 1) financial commitments; 2) policy, research and advocacy commitments; and 3) commitments for delivering services and products and strengthening health systems.

• Assess how these commitments have facilitated efforts to achieve the Global Strategy’s intended outcomes, and the overall goal of saving 16 million lives.

• Focus on an analysis in four selected thematic areas: 1) adolescent health; 2) family planning; 3) newborn health; and 4) advocacy. The latter will examine both advocacy-specific commitments and the advocacy impact that the Global Strategy has had on mobilizing support and catalysing RMNCH action generally.

• Improve transparency and promote mutual accountability for these commitments, by:

— publicizing details of the commitments and progress (if any) made against them;

— developing guidelines to support future voluntary commissioning of external audits on the implementation of commitments by commitment makers themselves; and

— exploring possibilities for ongoing self-reporting on commitments (supported by voluntary external audits).

The methods used for the PMNCH 2013 report include a web-based survey to collect data on the scope and content of commitments, which will be supplemented by a desk review of literature and key informant interviews.


reporting of women’s and children’s health and related issues, and to develop an approach that involves the media in the planning of MNCH advocacy.

2. Working with civil society

PMNCH planned to issue a report at its board in Johannesburg in June 2013 to detail the work over the past year on mapping national advocacy capacity and joint advocacy planning and budgeting. This involved CSO coalitions in 11 countries, including India, Nigeria, Ethiopia, and Indonesia.

With those national CSO coalitions, PMNCH plans to hold a regional workshop in Nairobi in August on budget-tracking for CSOs. This will build technical skills in resource and expenditure tracking, and map out advocacy strategies to convey that evidence. Partners in this discussion include Save the Children, WHO’s national health accounts team, the Open Health Initiative, E4A and the IPU, among others.

Way forwardDiscussions are underway to form a private-public alliance that can scale up national behavioural change and information campaigns in key countries on newborn health. This will support the new Global Newborn Action Plan and Every Woman Every Child/A Promise Renewed for Child Survival. The companies and alliances participating in the work include: DMI; the GSMA alli-ance of mobile phone operators; and McCann Erickson. They are supported by PMNCH, Saving Newborn Lives, USAID and the MDG Health Alliance.

PMNCH’s health care professional association members (FIGO, IPA, ICM) and civil society con-stituency (led by White Ribbon, IPPF, PATH, World Vision and Save the Children) have produced a proposal. This focuses on scaling up education and capacity building of professional members on key interventions relevant to care at the time of birth in selected countries in Africa. It also considers national advocacy for essential interventions linked to the recommendations of the United Nations Commission on Life-Saving Commodities. This will build on the 11 national CSO coalitions (see above), and link closely with the budget-tracking activity proposed in support of the implementation of the country accountability plans.

Box 11. The benefits of community-based monitoring systemsThere has been much research on the benefits of community-based monitoring systems. National statistics, information and data are often not well understood at the household and community levels, within specific socioeconomic and political contexts. Community based monitoring systems are based on the fact that relevant, local information and data about communities contributes to efforts to change and that investments are properly targeted and monitored.

World Vision promotes community ownership and engagement as critical parts of the accountability chain for health and works to strengthen the links between local and national level. World Vision focuses on the role of citizens in accountability supporting them to be able to monitor and influence government spending, both from domestic resources and overseas aid, on health, education and other services. Citizen Voice and Action brings together citizens, service providers, local government and civil society partners in a collaborative, facilitated group process designed to improve the quality of health services at the local level.

World Vision promotes community ownership and engagement as critical parts of the accountability chain for health and works to strengthen the links between local and national level. World Vision focuses on the role of citizens in accountability supporting them to be able to monitor and influence government spending, both from domestic resources and overseas aid, on health, education and other services. Citizen Voice and Action brings together citizens, service providers, local government and civil society partners in a collaborative, facilitated group process designed to improve the quality of health services at the local level.


Recommendation 9: Reporting Aid for Women’s and Children’s Health: OECD-DAC

GoalReporting aid for women’s and children’s health: By 2012, development partners request the Organisation for Economic Co-operation and Development – Development Assistance Committee (OECD-DAC) to agree on how to improve the Creditor Reporting System so that it can capture, in a timely manner, all reproductive, maternal, newborn and child health spending by development partners. In the interim, development partners and the OECD implement a sim-ple method for reporting such expenditure.


By 2012, development partners agree on the method Target met in 2012

By 2013, OECD has developed the guidance and instructions to support the new scoring system for RMNCH in the Creditor Reporting System and donors begin reporting using the new method

Implementation progressThe OECD Working Party on Statistics (WP-STAT) has worked to develop and refine reporting instructions and guidance for the new RMNCH marker since its approval last year. A proposal for modifications to the Converged Statistical Reporting Directives is being sent to members in order to incorporate the new marker definition and instructions into the directives.

PartnersThere are now 26 members of the OECD-DAC (25 countries plus the EU Institutions). Al par-ticipate and have voting power in the WP-STAT. Some multilateral organizations and non-DAC countries also attend WP-STAT meetings as observers. The 26 members are: Australia, Austria, Belgium, Canada, Czech Republic (joined May 2013), Denmark, EU Institutions, Finland, France, Germany, Greece, Iceland (joined March 2013), Ireland, Italy, Japan, Korea, Luxembourg, the Netherlands, New Zealand, Norway, Portugal, Spain, Sweden, Switzerland, United Kingdom and United States.

Way forwardThe RMNCH marker will be introduced into the Creditor Reporting System for 2014 reporting on 2013 flows and will be evaluated after a two-year trial period.

Recommendation 10: Global Oversight

Starting in 2012 and ending in 2015, an independent Expert Review Group (iERG) is reporting regularly to the United Nations Secretary-General on the results and resources related to the Global Strategy and on progress in implementing the CoIA’s recommendations.

Implementation progress and results■■ In September 2012, the iERG published its first report. It was presented to the United Nations Secretary-General at a high-level event during the United Nations General Assembly.

■■ In November 2012, the iERG participated in a consultation on the report and recommenda-tions with stakeholders at the CoIA Third Stakeholders’ meeting in Geneva.

■■ The iERG held a second stakeholder Consultation on 29 May 2013 in Kuala Lumpur, Malaysia.

■■ More than 15 partners will submit reports to the iERG to inform its reporting to the United Nations Secretary-General.


TABLE 5. INDEPENDENT EXPERT REVIEW GROUP MEMBERSHIP (AS OF OCTOBER 2012)a

Dr Richard Horton of the United Kingdom – Editor-in-Chief, The Lancet;

Mrs Joy Phumaphi of Botswana – Executive Secretary of the African Leaders Malaria Alliance (Mrs Phumaphi will take over the chair mandate from Dr Horton upon the release of the 2013 iERG report. Both will keep the status of co-chairs of the iERG);

Dr Carmen Barroso of Brazil – Director, International Planned Parenthood Federation (IPPF) Western Hemisphere Region;

Dr Zulfiqar Bhutta of Pakistan – Professor and Founding Chair of the Division of Women and Child Health, Aga Khan University, Karachi;

Mrs Kathleen Ferrier of the Netherlands – previous member of the Netherlands Parliament;

Dr Dean Jamison of the United States of America – Professor, School of Public Health, University of Washington;

Dr Tarek Meguid of Egypt – Associate Professor and Head of the Department of Obstetrics & Gynaecology at the University of Namibia School of Medicine;

Dr Miriam Were of Kenya – Global Health Workforce Alliance.

a In October 2012, one of the seven iERG members – Prof Marleen Temmerman – had to leave the group due to her new appointment as Director of the Reproductive and Research Department at WHO. In response, WHO initiated a call for submission of nominations to all stakeholders of the Global Strategy (7 July–7 September 2012). Given the load of the iERG work, two new members were taken on board: Dr Tarek Meguid from Egypt and Mrs Kathleen Ferrier from the Netherlands.

Way forwardThere is increased recognition that the iERG and the accountability framework have together formed a robust mechanism for monitoring and reporting progress on large multipartner initia-tives. As such, other initiatives are increasingly coming under the iERG purview, including: Family Planning 2020, the Commission on Life-Saving Commodities and the Global Vaccine Action Plan.


Implementing the iERG recommendations

In September 2012, the iERG presented its first annual report – Every Woman, Every Child: from commitments to action. This provides a detailed assessment of the current status of implemen-tation of the Global Strategy and an assessment of progress on the recommendations of the CoIA.

The iERG report makes six specific and significant recommendations of its own to accelerate progress towards MDGs 4 and 5:

1. Strengthen the global governance framework for women’s and children’s health;

2. Devise a global investment framework for women’s and children’s health;

3. Set clearer country-specific strategic priorities for implementing the Global Strategy and test innovative mechanisms for delivering those priorities;

4. Accelerate the uptake and evaluation of eHealth and mHealth technologies;

5. Strengthen human rights tools and frameworks to achieve better health and accountability for women and children;

6. Expand the commitment and capacity to evaluate initiatives for women’s and children’s health.

These iERG recommendations were prioritized during the CoIA Third Stakeholders’ meeting in November 2012. More than 70 partners gathered to assess progress towards the 10 CoIA recom-mendations and review the feasibility of the iERG recommendations. Recommendations 1, 2 and 5 were considered a priority as they represented key gaps in the work to date. Work towards the other recommendations was deemed to be already addressed through the different workstreams (i.e. Country Accountability Frameworks address country-specific strategic priorities; eHealth is addressing recommendation 3; and recommendation 6 is addressed by monitoring and evalua-tion of resources spent and results achieved.)

Recommendation 1: Global governance around the Global Strategy for Women’s and Children’s Health. Based on the success of the accountability model and recommendations from stake-holders, other initiatives are increasingly interested in using the accountability framework. The Commission on Life-Saving Commodities will use the existing accountability framework and report its progress through the iERG. Countries have encouraged WHO to support the increased coordination between the Commission on Life-Saving Commodities and the ColA – as well as all the initiatives under the Global Strategy for Women’s and Children’s health – to ensure the reporting burden of the countries is reduced. The Global Decade of Vaccines plan of action will use the accountability framework and report process through the World Health Assembly and the iERG.

To further the recommendation on global governance, an RMNCH Steering Committee has been established to more closely harmonise and coordinate funding streams and activities. Key donors and partner agencies are participating, including: Canada, France, Norway, Sweden, UK, US, UNFPA, UNICEF, WHO, World Bank, Gates Foundation, Clinton Health Access Initiative, PMNCH and the Office of the UNSE for Financing Health MDGs. Country representatives (Ethiopia, Nigeria, Senegal and Tanzania), are joined by the UN Foundation and the Executive


Office of the Secretary-General as observers. The Steering Committee aims to align activity around monitoring and reporting of results and to enhance mutual accountability and country ownership. The intent of this effort is about coordinating across initiatives and funding streams.

Recommendation 2: Investment framework for Women’s and Children’s Health. WHO in collabo-ration with PMNCH and the University of Washington will oversee the development of a global investment framework for women’s and children’s health. The first meeting of the working group responsible for data collection, analysis and report writing took place in Geneva from 25 to 26 February 2013. Expected outputs include a journal article, a summary of evidence and key mes-sages and a comprehensive technical report. The latter is due to be published in December 2013, in conjunction with the launch of the report of The Lancet Commission on Investing in Health.

Box 12. World Health Assembly governance – closing the accountability loopMember States of the World Health Assembly (WHA) have passed three resolutions related to initiatives under the umbrella of the Global Strategy and the Every Woman Every Child movement. This ensures that Member States will report progress towards the targets and goals of the different initiatives.

The 65th WHA endorsed the Global Decade of Vaccines, urging Member States to: “report every year to the regional committees during a dedicated Decade of Vaccines session, on lessons learnt, progress made, remaining challenges and updated actions to reach the national immunization targets”. Member States further requested the World Health Organization to “monitor progress and report annually” on global immunization targets, using the proposed accountability framework to guide discussions and future actions.

The 65th WHA also “reaffirmed WHO’s key role in the implementation of the Commission on Information and Accountability for Women’s and Children’s Health”. It urged Member States to honour their commitments to the Global Strategy and to strengthen efforts to improve women’s and children’s health by implementing the 10 CoIA recommendations and to “provide support to the independent Expert Review Group in its work of assessing progress in the Global Strategy”.

The 66th WHA in May 2013 adopted a resolution on the “Implementation of the Recommendations on Life-saving Commodities for Women and Children”. The Commission on Life- Saving Commodities will also use the existing accountability platform and report to the WHA.

FIGURE 5.

Visit www.everywomaneverychild.org

CoIA Independent expert Review Group

FP2020 Born too soon

A Promise Renewed

Country leadership & Implementa?on

Global Vaccine Ac?on Plan

Innova?on Working Group

Key advocacy events and cataly?c ini?a?ves in support of Every Woman Every Child

Commission on Life-‐saving Commodi?es

Newborn Ac?on Plan

Pneumonia and Diarrhoea


Recommendation 5: Strengthen human rights tools and frameworks to achieve better health and accountability for women and children. Both the health and human rights communities increas-ingly recognize the importance of a human rights-based approach to women’s and children’s health. In direct response to the iERG recommendation, WHO, the Office of the United Nations High Commissioner for Human Rights (OHCHR) and PMNCH initiated action to further incor-porate human rights activities into ongoing efforts to strengthen accountability for women’s and children’s health. Recent initiatives are a testimony of this:

■■ In September 2012, the United Nations Human Rights Council adopted a technical guidance document on the application of a human rights-based approach to eliminate preventable maternal mortality and morbidity.

■■ In March 2013, the Council held a full-day high-level discussion on children’s right to health, and adopted a resolution on the subject, which invited WHO to prepare a study on under-five mortality as a human rights concern. The report on the study will be submitted to the Council in September 2013.

■■ In March 2013, the iERG and OHCHR organized a workshop on the use of human rights treaty bodies and development of human rights indicators for RMNCH to enhance rights-based monitoring of women’s and children’s health.

■■ The Council adopted its second resolution on birth registration, in which it emphasized the importance of the child’s right to an identity, and of the role of effective registration systems as a crucial contribution to children’s health.

■■ In February 2013 the United Nations Committee on the Rights of the Child adopted its General Comment on the right to the highest attainable standard of health. In this it articulates the content of the child’s right to health, as contained in the Convention on the Rights of the Child. It also outlines the core obligations of governments and other stakeholders to ensure that all children receive the care they need to survive and enjoy optimal health.

In response to the iERG recommendation, the 2013 accountability workplan includes a human rights component. This requires WHO, OHCHR, PMNCH and other key partners to support a series of comprehensive rights-based desk reviews in Malawi, Tanzania, Uganda and Nepal. The aim is to analyse laws and policies that have a bearing on maternal and child mortality and mor-bidity, and to analyse the availability of accountability mechanisms for claims related to maternal and child health. These will be translated into case studies, and recommendations will be shared at a regional event in late 2013.


Expenditure report

The overall four-year (2012–2015) budget for the accountability work is US$ 96.5 million. This is an increase from the original US$ 88 million in order to provide additional financial and technical support to countries to implement their CAFs and to integrate recommendations from the iERG.

There is an estimated funding gap of US$ 56 million for the projected implementation of the workplan. This includes a US$ 5 million gap for 2013, because the number of countries that are developing CAFs to implement the accountability framework exceeds the expectation. Furthermore, resources are needed to continue to support countries in the second phase dur-ing 2014–2015. This is a significant risk, so efforts will continue to better measure and report on progress and attract additional funding from donors. It should be further underscored that the overall funding required to support country implementation significantly exceeds the workplan funding estimate. To effectively achieve such an objective in countries requires the mobiliza-tion of resources well beyond the “catalytic” funding included in the workplan budget. This will require additional effort for resource mobilization for each country, taking account of interested partners and donors and the development of an investment plan for each country.

To date, WHO has received US$ 34 million. Two further pledges are due to be received of US$ 2.9 million in 2013 and US$ 2.3 million in 2014, thanks to the support of the governments of Canada, Norway and the United Kingdom. The Global Fund, GAVI, USAID and Gates also contribute to different streams of work, as highlighted in the different sections. Of this, approximately US$ 29 million was made available for programme implementation. To date, US$ 24.2 million has been disbursed of funds made available to date. Forty-seven percent of the funds go to Country Accountability Frameworks. Partners have received 24% of the funds; the iERG 8% and WHO 22% (see figure below for the breakdown). Annex 2 also provides a breakdown of funds across the different workstreams.

FIGURE 6: FUNDING SITUATION TO DATE

US$ 96.5 m budget over 2012–2015

Allocation US$ 24.3 m

WHO 22%

Partners 24%

Countries 47%

iERG 8%

Funding ap 61 million 59%

Funds recieved 40 million 36%

Allocation US$ 24.2 M

Funding situation to date

Funding Gap: 56.5

million 59%

PSC

Funds received: 40 million

41%

US$ 96.5m budget over 2012-‐2015

WHO 22%

Partners 24%

Countries 47%

iERG 8%

Funding ap 61 million 59%

Funds recieved 40 million 36%

Allocation US$ 24.2 M

Funding situation to date

Funding Gap: 56.5

million 59%

PSC

Funds received: 40 million

41%

US$ 96.5m budget over 2012-‐2015


US$ 11 million is going to countries:

■■ US$ 9.2 million is for the 36 countries that have received catalytic funding of US$ 250 000 to implement their CAFs;

■■ US$ 2 million is to support countries (i.e. national workshops and technical support).

The distribution of funds across the different workstreams is consistent with the prioritization that countries defined in their CAFs (i.e. monitoring of results, MDSR and CRVS are the areas that the majority of countries prioritized).

FIGURE 7. EXPENDITURES AND FUNDING FOR 2013 AND BEYOND Funding and pledges to date, US$

Expenditures and funding for 2013 and beyond Funding and Pledges to Date

US$ 24.3 has been distributed:   47% to countries (assessments, roadmap development, and roadmap funding);   24% to partners;   15% to WHO;   8% to the iERG and   6% for project management An addiOonal 24 countries will be requesOng catalyOc fund of US$ 250,000 in the upcoming 2-‐3 months. There is an immediate need for US$ 6 million to support these countries.

Donors 2011 2012 2013 2014 2015 Totals

CIDA 155,300 19,822,162 -‐ -‐ -‐ 19,977,462

DFID -‐ 796,133 1,592,267 2,388,420 -‐ 4,776,820

NORAD 155,045 11,553,752 2,995,572 -‐ -‐ 14,704,369

Totals: 310,345 32,172,047 4,587,839 2,388,420 -‐ 39,458,651

Less 13% PSC 4,182,366 596,419 310,495 -‐ 5,129,625

Available for Program ImplementaMon

270,000 27,989,681 3,991,420 2,077,925 -‐ 34,329,026


Risks and challenges

Countries and their partners have made progress to implement the recommendations of the CoIA, but significant challenges remain. Priority actions include a need to 1) review the feasibility of reaching the targets set in the strategic plan 2) leverage the resources available for the ColA follow-up to achieve greater country progress; 3) reach out to a broader range of partners than is currently engaged in the implementation of the workplan; 40) better understand the support countries need to implement their country accountability work; and 5 facilitate access to that sup-port. Accelerating country progress will be the key to success.

Accelerating country progress

As momentum builds, countries are increasing their requests for support to implement the CoIA recommendations, so there is an urgent need to scale up the response to countries. However, the capacity to meet all country demands for technical support is limited. One potential model for handling demand would require the regions play a central role in advocacy and coordination, and in monitoring progress, sharing information and responding to country needs. It would also be valuable to map available capacity across all the CoIA recommendations – including from donors and other stakeholders – so that all sources of support for countries can be tapped.

Country financing risks

As noted above, the funding required to support country implementation significantly exceeds the workplan funding estimate.

As they currently stand, the country accountability frameworks are geared more towards short- and medium-term activity than towards longer-term investment that will achieve systematic change. In some cases, relatively little targeted expenditure could potentially result in long-term advances. This point is illustrated for Recommendation 1 by the recent Health Metrics Network CRVS country-costing study.1 It shows that, in South Africa, an estimated annual increase of US$ 1.2 million in spending would lift the number of birth and death registrations from current levels of coverage to 100%. Similar analysis should ideally be completed for all aspects of the health system requiring improvement to achieve the ColA recommendations.

This highlights the need to leverage the resources available for ColA follow-up to achieve greater country progress. It is essential to develop a proactive strategy to reach out to a broader range of partners than is currently engaged in the implementation of the workplan. This should be followed by a mapping of interested donors in each country and a combined approach to government and donors to raise the resources needed to meet the recommendations. Some countries are likely to lack the domestic resources to implement the country improvements needed, so country capac-ity to invest should be incorporated into the financing requirements. Simultaneously, advocacy efforts aimed at parliamentarians should have a clear focus on encouraging them to mobilize domestic resources.

1 http://www.who.int/entity/healthmetrics/resources/CRVS_investment_case.pdf.


Approach to fragile and conflict states

The selection of some of the world’s poorest and most fragile countries for accountability improvements inevitably means that progress will be difficult and slow in these countries, result-ing in poor overall progress and an inability to access vulnerable groups. It would be useful to identify a sub-set of countries that are fragile states. This would enable specific discussions on what can be achieved in these countries, rather than continuing to group them with countries that are well able to make progress.

Getting specific on achievable outcomes

A number of the recommendations of the CoIA are somewhat general in their intent, and need to be linked as clearly as possible to how they are expected to improve RMNCH outcomes. For example, Recommendation 3 – “By 2015, countries integrating Information and Communications Technologies in national health information system and health infrastructure” – is not clearly linked to the benefits for RMNCH. Thus, this objective could potentially be achieved in a sig-nificant number of countries, but be of no discernible benefit to RMNCH. There are other rec-ommendations where it would be beneficial to map the specific links between the strategy and RMNCH benefits.

Prior to the preparation of the next workplan, it would be useful to analyse each recommenda-tion to be sure that the combined efforts of the CoIA follow-up will lead to measurable outcomes for RMNCH, and that the results expected to be achieved , including the number of women and children reached by 2015 are clearly articulated.


Looking forward

There is a need for a single accountability framework that brings together all the initiatives under the umbrella of the Global Strategy for Women’s and Children’s Health. To ensure global gov-ernance and a streamlined approach to implementing the different initiatives, it is important to move towards the “three ones”: one global monitoring framework with a set of global indica-tors and aligned reporting; one country M&E platform with common investments in informa-tion systems and country capacity; and, one high-level global review mechanism. The iERG is a mechanism to promote synergies under different initaitves under global strategy – and to anchor global governance.

Global governance

While the iERG has stimulated increased focus on global governance, more remains to be done to ensure the initiatives being undertaken combine to deliver measurable results for women and children. Action is needed to maximize the combined country-level impact of the various RMNCH initiatives – including the Commission on Life-Saving Commodities, the Global Vaccine Action Plan and Family Planning 2020. It is necessary to link all of these efforts to accelerate progress towards MDGs 4 and 5. This is the crux of the accountability that the global community has been tasked with achieving.

Regional engagement

Similarly, a move towards more regional engagement is required to improve governance and coordination among the different workstreams implementing the CoIA recommendations. This will help consolidate approaches to providing technical support to countries and greater inclu-sion of regional and country-level partners. Regional meetings that bring together countries implementing the CAFs would be a useful mechanism to review bottlenecks and lessons learned, and to coordinate technical support to countries with a wide range of partners.

Effective implementation of the workplan will require a comprehensive understanding of coun-try stakeholders and donors, so that all can be effectively engaged in this effort. This might be impossible to achieve in some countries. However, mapping and coordination of stakeholders and donors would be valuable in those countries that WHO has identified as priorities for early progress.

The focus must remain squarely on countries, and the priority must be to: 1) leverage the resourc-es available for the CoIA follow-up to achieve greater country progress; 2) reach out to a broader range of partners than is currently engaged in the implementation of the workplan – in particu-lar USAID-funded programmes on RMNCH (these represent billions of dollars of expenditure worldwide and their results should be incorporated into the reporting against the workplan); 3) understand the support that countries need to implement their country accountability work; and 4) facilitate access to that support.


Engaging a wider range of partners to support countries

As countries report progress towards their CAFs, a set of “fast track” or “early progress” coun-tries is emerging. Similarly, fragile and politically unstable states and countries in conflict are seen to be lagging behind. In the next few months, discussions will take place about how best to support countries to fast track results. Incentives such as additional funding for CAFs will continue to drive the momentum. A mechanism is also needed to support fragile states where progress is slow. There is a need to engage with a broader range of partners to accommodate the different needs of the various countries – through regional institutions, academic institutions, civil society and NGO service providers – and to provide support to countries.

Programme management

Prior to the preparation of the next workplan, it would be useful to analyse each recommenda-tion to be sure that the combined efforts of the CoIA follow-up will lead to measurable results for RMNCH, and that the results expected to be achieved by 2015 are clearly articulated.

A results-based management system would enable the management of the programme to close-ly track expenditures that are directly linked to progress, outputs and outcomes.

Stakeholder consultations to take stock of progress

The stakeholders meeting held in November 2012 served as a platform to review the recom-mendations of the iERG’s 2012 report and to prioritize and plan for their implementation. Given the positive feedback from the 2012 meeting, Canada has expressed interest in hosting a similar stakeholder meeting with the iERG where the 2013 recommendations can be discussed among the different implementaing partners. This will also provide the opportunity to critically review implementation mid-way into the four-year initiative.

Conclusion

Important progress has been made towards implementing the CoIA’s 10 recommendations for improved information and accountability. However, there is a clear need for more coordinated action by all countries and partners. Countries require more support to implement their account-ability work as we transition from the advocacy and planning stage to focus on country action and results.

In the future, efforts should focus on adapting strategy to achieve specific and measurable bene-fits for women’s and children’s health. Wherever possible, cross-cutting themes and technologies should be considered across all recommendations to achieve synergies and enhanced impact.

List of annexes

■■ Annex 1: 2011 Strategic Workplan – table with targets for each CoIA recommendation;

■■ Annex 2: Financial report;

■■ Annex 3: Breakdown of country catalytic funding across work areas.


References

■■ 2013 workplan: http://www.who.int/entity/woman_child_accountability/Accountability_StrategicWorkplan2013.pdf

■■ iERG 2012 report: http://www.who.int/woman_child_accountability/ierg/news/ierg_2012_report_launch/en/index.html

■■ November 2012 stakeholder meeting: http://www.who.int/woman_child_accountability/news/third_stakeholder_meeting_GS_COIA_iERG_19_20_november_2012/en/index.html

■■ Translating Recommendations into Action: September 2011 Strategic Workplan: http://www.who.int/woman_child_accountability/about/coia/en/index7.html

■■ 2012 Progress Report: Translating Recommendations into Action: First Progress Report on Implementation of Recommendations: http://www.who.int/entity/woman_child_accountability/COIA_Report_web_v2.pdf.

Acknowledgements

This report was written by the working group leads contributing towards the implementation of the recommendations of the Commission on Information and Accountability for Women’s and Children’s Health. The report was coordinated and compiled by the World Health Organization.

Lead authors: Flavia Bustreo, WHO; Marie-Paule Kieny, WHO; Jessie Schutt-Aine, WHO; Kathy O’Neill, WHO; Jane Thomason, Abt Associates; Ties Boerma, WHO; Elizabeth Mason, WHO.

Working group members and key contributors Krishna Bose, WHO; Maurice Bucagu, WHO; Simon Day, WHO; Carmen Dolea, WHO; Joan Dzenowagis, WHO; Tessa Edejer, WHO; Andres de Francisco, PMNCH; David Evans, WHO; Stafan Germann, World Vision International; Tore Godal, Government of Norway; Sowmya Kadandale, WHO; Ramesha Krishnamurthy, WHO; Geir Lie, WHO; Lene Lothe, Norad; Matthews Mathai, WHO; Sue Mbaya, Inter-Parliamentary Union; Lori McDougal, PMNCH; Garrett Mehl, WHO; Annex 3: Breakdown of country catalytic funding across work areas; Aimee Nichols, OECD; Ingvar Olsen, Norad; Carole Presern, PMNCH; Jennifer Requejo, Johns Hopkins University School of Public Health; Dag Roll-Hansen, WHO; Florence Rusciano, WHO; Neema Rusibamayila, Government of Tanzania; Anneke Schmider, WHO; Marcus Stahlhofer, WHO; Michelle Strong, WHO; Jean Touchette, OECD; Phyllida Travis, IHP+; Nathalie Van de Maele, WHO, Benjamin Yung, Canadian International Development Agency.

Annexes


Annex 1Original Strategic Workplan with recommendations, indicators and targets

ACTION ITEM INDICATOR / TARGETS LEAD PARTNER COMMENTS

0. General

Develop country plans to augment accountability that are based on a rapid assessment and address priority areas for strengthening national accountability processes

At least 50 countries have made commitments and completed COPAAs by 2013

Countries: governments, other institutions

With TA from UN, bilaterals, academic institutions

Partnerships, CSO

(workplan 1.2.3)

1. By 2015, all countries have well-functioning health information systems, including surveys, facility and administrative sources, and have taken significant steps to establish a system for registration of births, deaths and causes of death.

Strengthening of country civil registration and vital statistics systems (CRVS), to better count maternal, newborn and child deaths

At least 50 countries have completed an assessment and developed a plan, and have taken significant steps towards implementation by 2015 (>20 by 2013)

Countries, multiple sectors involved

HMN/WHO and UN Statistical Division

Strong country commitment to CRVS strengthening critical

Expanding the HMN MOVE-IT initiative

(workplan 1.2.2)

Strengthening of country health information systems to support timely and accurate monitoring of national health strategies accurate

At least 50 countries have timely and accurate core coverage indicators data to inform annual reviews, with appropriate data-quality controls (20 by 2013)

Countries, health and statistical sectors

UN

HMN, PMNCH

Involves well-functioning HMIS (see also rec.3), combined with regular household surveys

(workplan 1.2.1)

2. By 2012, a core set of 11 indicators on reproductive, maternal and child health, disaggregated for gender and other equity considerations, are being used for the purpose of monitoring progress towards the goals of the Global Strategy.

The core indicators included in monitoring systems in countries

Monitoring incorporates equity, including main stratifiers (gender, socioeconomic position, sub-national data) to track and target disadvantaged populations

At least 50 countries use and have up-to-date accurate data on the core indicators, disaggregated, as part of their M&E systems by 2013

Global partners have streamlined reporting systems around the core indicators by 2012

Countries, health and statistical sectors

Partnerships (GAVI, Global Fund, HMN, PMNCH)

UN

Comprehensive plans developed and implemented for countries with highest burden for monitoring progress towards the core indicators

Additional information and new resources required to institutionalize quality of care assessments in countries

(workplan 1.2.1)



3. By 2015, all countries have integrated the use of Information and Communication Technologies in their national health information systems and health infrastructure.

Innovation through ICT is used to improve the performance of the health information system, (including surveillance of maternal death), facility reports, and administrative data, and data sharing, supported by national eHealth strategies involving all relevant stakeholders

Accelerate the consultation process to develop required standards for increased interconnectivity and common standards

At least 50 countries have developed and are implementing national eHealth strategies, including specifics on how this benefits information and accountability for women’s and children’s health, by 2015

Countries

Private sector, CSO/NGO

ITU, WHO, other UN agencies

Improved coordination between existing initiatives and bodies to support such as Broadband Commission, Digital Health Initiative, the World Bank, the Innovation Working group, UN-DESA, etc.

(workplan 1.2.1)

4. By 2015, all 74 countries where 98% of maternal and child deaths take place are tracking and reporting, at a minimum, two aggregate resource indicators: 1) total health expenditure by financing source, per capita; and 2) total reproductive, maternal, newborn and child health expenditure by financing source, per capita.

Increase country capacity to routinely track health expenditures in ways consistent with the national health accounts framework

Build capacity for RMNCH specific expenditure tracking at global, regional and country levels

At least 50 countries use and have up-to-date and accurate data on the two indicators, as part of their M&E systems by 2013

WHO, World Bank, USAID with technical experts (academia, regional networks, other organizations)

Tracking private sources would be difficult on annual basis, but government and donor expenditures could be tracked annually.

(workplan 1.2.3)

5. By 2012, in order to facilitate resource tracking, “compacts” between country governments and all major development partners are in place that require reporting, based on a format to be agreed in each country, on externally funded expenditures and predictable commitments.

H4 and UN support countries in developing country agreements with external partners, and external partners encouraged to comply

At least 50 countries have formal agreements with donors by 2015

H4 and UN support countries. IHP+ playing a role in several countries. Bilaterals and CSO/NGOs encouraged to support the process through their country representatives

6. By 2015, all governments have the capacity to regularly review health spending (including spending on reproductive, maternal, newborn and child health) and to relate spending to commitments, human rights, gender and other equity goals and results.

Development partners will commit to strengthen capacity related to accountability processes in an additional 10 countries each year, prioritizing those with the highest burden of women’s and children’s ill health

All development partners, linking recommendations 2 and 4 above

(workplan 1.2.3)



7. By 2012, all countries have established national accountability mechanisms that are transparent, that are inclusive of all stakeholders, and that recommend remedial action, as required.

Plans for national accountability mechanisms established all countries building on existing initiatives and inclusive of all stakeholders

All countries will report on the chosen mechanism to the ERG

From 2011, countries with support of development partners will obtain their own baseline data for the indicators recommended in the Commission report.

At least 50 countries have regular national health sector review processes that meet basic criteria including broad stake holder participation

At least 20 countries have made progress in engaging political leaders and financial decision makers in health

At least 50 countries have held at least one Countdown event

All countries provide relevant information to the ERG for review on an annual basis starting 2012

Countries

CSOs, UN

(workplan 1.2.3)

8. By 2013, all stakeholders are publicly sharing information on commitments, resources provided and results achieved annually, at both national and international levels.

H4 will work with other UN partners to further develop current databases on key indicators and disseminate effectively

From 2011, monitoring of adherence to the IHP+ principles will also be an integral part of accountability for the Global Strategy and IHP+ reports will be made public on the global website Every Women Every Child

At least 50 countries have effective data sharing and dissemination mechanisms

Global partners have up-to-date databases on women’s and children’s health and effective dissemination of country level and global data on the core indicators

In 2011, governments and partners should further clarify their announced financial commitments (up to US$ 40 billion) to the Global Strategy for Women’s and Children’s Health to enable these commitments to be tracked at global and country level

H4+

Academic and research institutions

Countries

Donors

CSOs

(workplan 2.1)

9. By 2012, development partners request the OECD-DAC to agree on how to improve the Creditor Reporting System so that it can capture, in a timely manner, all reproductive, maternal, newborn and child health spending by development partners. In the interim, development partners and the OECD implement a simple method for reporting such expenditure.

Development of improved Creditor Reporting System

By 2012, development partners agree on the method

By 2013, OECD has developed the technology to support the new Creditor Reporting System and donors begin reporting using the new methods

Global level: OECD-DAC for the database, with inputs from EC, WHO, World Bank, USAID on methods

PMNCH in the short run estimating donor commitments and disbursements for women’s and children’s health until DAC database revised and relatively complete

(workplan 2.2)



10. Starting in 2012 and ending in 2015, an independent Expert Review Group is reporting regularly to the UN Secretary-General on the results and resources related to the Global Strategy and on progress in implementing this Commission’s recommendations.

WHO will facilitate an open and transparent process to solicit nominations for an expert review group to review progress against the Global Strategy and the implementation of the Commission’s recommendations

By September 2011 the members have been appointed

From September 2011, ERG members with support of the WHO secretariat will start preparing for a first meeting of the ERG in the second quarter 2012

WHO (workplan 2.3)


Annex 2Financial expenditures by work area

Recommendations and workstreams

Total disbursements (US$) as of 22 May 2013

0.2 Country accountability self-assessment 3 070 961

Recommendation 1: Vital Events and Health Information Systems1.1. CRVS 2 033 264

1.2 MDSR and Quality of Care 2 449 277

1.3 Monitoring of results (Health Information Systems and data quality) 2 977 827

Recommendation 2: Health Indicators2.1 Global Monitoring of results 671 604

Recommendation 3: Innovation and eHealth3.1 eHealth and Innovation 1 163 325

Recommendation 4: Resource Tracking4.1 Resource tracking with main indicators 2 206 167

Recommendation 5: Country Compacts5.1 Compacts in place 396 152

Recommendation 6: Reaching women and children: capacity to review spending6.1 Capacity to review health spending 653 664

Recommendation 7: National Oversight7.1 Health Sector Reviews 1 099 007

7.2. Advocacy and outreach (parliamentarians, Countdown, civil society) 1 714 706

7.3 Country Countdowns (dissemination, interpretation use) 388 900

Recommendation 8: Transparency (linked to advocacy, Countdown, monitoring resources)8.1 Transparency: 1 078 899

Recommendation 9: Reporting aid for women’s and children’s health

Recommendation 10: Global Oversight10.1 Independent Expert Review Group 2 470 000

Overall 11.1 Project management/secondments 1 896 000

PSC (13%) 2 483 031

Grand Total (net of PSC) 24 269 753


Annex 3Breakdown of country catalytic funding across work areas1

1 Catalytic funding provided to countries to fill in gaps in national plans as relates to the CoIA recommendations.

Countries

Breakdown of catalytic funding request by priority area (000 $)

Award Distribution

date

Total amount

distributed (000 $)C

RVS

Mon

itorin

g Re

sults

MD

SR

E-he

alth

In

nova

tion

Reso

urce

tr

acki

ng

Revi

ews

Adv

ocac

y

Benin 18.5 39.5 131 – 10 30 21 02-Jul-12 250

Burkina Faso 28 57 27 34 47 22 35 20-May-13 250

Cameroon 60 110 54 10 16 – – 14-Dec-12 250

Comoros 24.628 14.238 100 7.535 49.822 4.135 50 20-May-13 250

DRC 40 125 5 – 40 – 40 11-Apr-13 250

Ethiopia 125 – – – 50 – 75 16-Nov-12 250

Guinea 88 39 33 36 12 40 5 20-May-13 250

Kenya 40 30 40 20 40 20 50 23-Apr-13 250

Lesotho 74.5 23.2 84 30.5 14.4 11.2 12.2 26-Mar-13 250

Liberia 45 17.5 118 17.5 10.5 13.5 28 18-Mar-13 250

Madagascar 115 22 54.5 15 4 18.5 21 16-Nov-12 250

Malawi 42 30 30 22 60 26 40 21-Aug-12 250

Sierra Leone – 235.5 – – – 14.5 – 20-Sep-12 250

Tanzania-Mainland/Zanzibar

102.5 45 60 45 42.5 20 35 04-Jul-12 350

Togo 69 129 – – 30 22 – 21-Sep-12 250

Uganda – 30 130 10 30 10 40 25-Sep-12 250

Zambia 60 65 45 50 30 5-Mar-13 250

Zimbabwe 75 120 – – 40 – 15 20-Sep-12 250

Bolivia 62.5 50 50 17.5 25 20 25 27-Mar-13 250

Guatemala 83 25 50 10 32 30 20 27-Mar-13 250

Afghanistan 26.5 29.9 46 33 15.5 60 39 17-Apr-13 250

Morocco 20 80 60 30 30 – 30 21-Feb-13 250

Pakistan 13 84 47 39 26.5 16.5 24 20-May-13 250

Yemen 35 30 122 – 63 – – 11-Apr-13 250


Countries

Breakdown of catalytic funding request by priority area (000 $)

Award Distribution

date

Total amount

distributed (000 $)C

RVS

Mon

itorin

g Re

sults

MD

SR

E-he

alth

In

nova

tion

Reso

urce

tr

acki

ng

Revi

ews

Adv

ocac

y

Kyrgyzstan 39 18 103 52 19 7 14 20-May-13 250

Tajikistan 35 15 105 23 35 10 27 11-Apr-13 250

Dem. People’s Rep. of Korea

50 90 15 70 10 5 10 30-Jan-13 250

Myanmar 46 61 50 51 20 10 12 20-May-13 250

Nepal 49 83 40 38 12.5 18.5 9 30-Jan-13 250

Cambodia 113.5 54 – – 82.5 – – 7-Feb-13 250

Lao PDR 50 90 70 – 10 30 – 11-Jul-12 250

Papua New Guinea 75 40 25 – 80 – 30 26-Nov-12 250

Philippines 95 40 70 20 25 – – 10-Oct-12 250

Viet Nam 58 117 40 10 – – 25 16-Nov-12 250

Solomon Islands 55 90 105 – – – – 13-Jul-12 250

Total amount distributed 1 913 2 129 1 910 641 1 032 459 762 8 850

Count of countries 33 34 30 23 32 23 27 35