- Email: [email protected]
Moving ahead: what will a renewed Countdown to 2030 for Women and Children look like?
Viewpoint
Moving ahead: what will a renewed Countdown to 2030 for Women and Children look like? Zulfiqar A Bhutta, Mickey Chopra
The Countdown to 2015 initiative (Countdown) represents a remarkable consortium of academicians, UN agencies, and development partners, which over the past decade, has focused its attention on tracking and analysing coverage of key interventions for reproductive, maternal, newborn, and child health (RMNCH) across 75 high burden countries that account for more than 95% of global maternal and child deaths. Initially started to ensure follow-up on the landmark Lancet Child Survival series,1,2 with innovative consolidation and presentation of coverage data on key interventions by country and regions,3 Countdown rapidly evolved with an expansion of its mandate to include reproductive and maternal health indicators across the continuum of care4 and more recently, analysis of nutrition trends and health policies.5 Countdown is also an example of the collective power of champions, innovative scientific and collaborative work across academic groups, civic society organisations, and UN agencies and partnerships across various sectors. Elements that have worked include strong buy-in from the UN and development agencies and the legitimacy of Countdown analysis by countries. Important strengths of Countdown have included multidonor support, relatively flexible governance and technical structures, strong links to the Partnership for Maternal and Child Health, and more recently to the independent expert review group (iERG) of the UN Secretary General for monitoring MDGs 4 and 5. Countdown’s core work on monitoring and measuring coverage of key interventions to affect MNCH interventions across the continuum of care represents one the major sources of consolidated information that governments, development agencies, civic society organisations, and the iERG have used in their work. Some aspects of Countdown’s work have also been challenging especially financial dependence on a limited set of donors, perceptions of independence in view that much of its core funding flowed through UN agencies, slow devolution of technical work to the regions, and relatively low-key advocacy. The latter is also evidenced by a gradual transition from standalone Countdown meetings as was the case in 2005 and 2008 to more limited sessions and visibility in other global MNCH meetings since. The release of its final report and the adoption of a new set of global Sustainable Development Goals (SDGs) invoke the question of what next for the Countdown? There are several core features of Countdown that should be preserved as we move into the SDG era. The collation, presentation, and analysis of a core set of
metrics centred on the coverage of crucial lifesaving interventions remains pertinent and critical to continued monitoring of SDG 3 (ensuring healthy lives and promotion of well being for all at all ages). Countdown further developed a range of equity measures across wealth quintiles and other markers such as geography, sex, and ethnicity6 that will be important to retain and link to assessments of equitable impacts of universal health care on MNCH. Of late, the group’s foray into geospatial analysis of inequities represents a powerful set of instruments to affect policies and investments. These must underpin any future monitoring of progress and accountability. A core working group on health financing has monitored global resource flows with a specific focus on overseas development assistance for RMNCH and sequential assessments of financing.7–9 Additional analyses of health systems and policies have allowed insight into awareness within countries of evidence-based key interventions for RMNCH and subsequent policy development and implementation at scale.10 A major development in recent years has also been the conscious move to analyse factors determining RMNCH progress at national or subnational level. Examples of these Countdown country case studies include insightful analyses of progress in child survival in Niger,11 maternal health in Bangladesh,12 and progress across RMNCH in Tanzania.13 At least six further case studies are underway in a range of countries including Peru, Pakistan, Afghanistan, Kenya, and Malawi and have engaged local experts and institutions as well as regional collaborations. Despite other similar exercises more recently,14 Countdown remains the dominant global group making available to countries a wide range of technical, financial, and political support for multistakeholder capacity development for monitoring and evaluation. In view of Countdown’s regular inputs to the iERG in monitoring global progress in relation to Milennium Development Goals (MDGs) 4 and 5,15 it should continue with support to the newly proposed independent accountability panel for RMNCH. Multistakeholder partnerships, RMNCH focus, shift to regional and national support, and continued development of improved scientific methods will, we believe, keep the Countdown process relevant for the forthcoming SDG era.16 There is clear recognition of the need to address issues that go beyond mortality. The challenge would be to link the Countdown process to emerging issues, such as adolescent health and noncommunicable diseases without sacrificing the core mission of addressing RMNCH. The new global strategy
www.thelancet.com Published online October 16, 2015 http://dx.doi.org/10.1016/S0140-6736(15)00527-9
Published Online October 16, 2015 http://dx.doi.org/10.1016/ S0140-6736(15)00527-9 See Online/Review http://dx.doi.org/10.1016/ S0140-6736(15)00519-X Robert Harding Chair in Global Child Health and Policy, Centre for Global Child Health, Hospital for Sick Children, Toronto, ON, Canada (Prof Z A Bhutta PhD); Center of Excellence in Women and Child Health, The Aga Khan University, Karachi, Pakistan (Prof Z A Bhutta); and Lead Health Specialist, World Bank, Washington DC, USA (M Chopra MD) Correspondence to: Prof Zulfiqar A Bhutta, Centre for Global Child Health, Hospital for Sick Children, Toronto, ON M5G 0A4, Canada [email protected]
1
Viewpoint
for Every Woman Every Child (EWEC)17 along with the emergence of initiatives such as the Global Financing Facility (GFF) for RMNCH offers an opportunity to do exactly this and reach beyond the traditional health sectors to include social determinants of health.18 There is also the unique opportunity to link the EWEC and delivery strategies with core intervention coverage assessment and the equity agenda that Countdown has long espoused, and could well offer an approach to ensure that key evidence-based interventions and actions for the most marginalised women and children are not lost in the quest to address all sectors and determinants. With increasing capacity within agencies and the UN system, strategies such as the “Call to Action”19 and other groups undertaking analyses for monitoring and accountability,20 Countdown will be one of several sources of information for accountability for RMNCH within the SDGs, but aims to provide high value inputs and generate quality products. The three pillars of the new EWEC strategy17 include “survival” hence ending preventable maternal, child, and adolescent mortality, ensuring that all children and adolescents “thrive” and achieve their full growth and developmental potential and “transformation” of society to create a peoplecentred movement for sustainable change. Countdown will work with concerned agencies to help to develop an evaluation and analytical plan to monitor progress for this strategy. So what might the new Countdown to 2030 look like? Notwithstanding structural and organisational details, the refreshed Countdown should aim to link strongly to the principles of independent and robust accountability from the very outset with broad stakeholder support. Although Countdown should continue to maintain strong links with UN partners and bilateral funding agencies, its core principles of independence, scientific rigor, and work streams for technical improvements in measurement methods must be protected. In view of the need for moving to a country-focused monitoring and evaluation and advocacy agenda, Countdown should aim to function with much greater devolution to regions and key countries with a so-called hub and spokes model. These regional hubs will also serve to enhance and develop capacity within the countries for addressing RMNCH progress at not mere national level, but increasingly with subnational granularity and a focus on action and implementation. Countdown should continue to work closely with global agencies engaged in periodic household level surveys such as demographic and health or multiple indicator cluster surveys, to move away from mere monitoring of coverage to also embrace the concept of quality of care, and hence effective intervention coverage. Increasing focus on models for inclusion of findings from rigorous civic registration and vital statistics systems would improve the timeliness and local availability of information, and must be a strong theme for the future. 2
There will need to be enhanced focus on newer analytical methods and engagement of a new generation of academic bodies and leaders, especially in highburden settings, to ensure that the goals of the new EWEC initiative are achieved within the timeframe the world has set itself. Contributors ZAB and MC jointly wrote this Viewpoint and approved the final version. Declaration of interests ZAB and MC have been co-Chairs of the Countdown for 2015 coordinating committee since 2006 and 2009, respectively. These are honorary, non-remunerated positions. We declare no other competing interests. References 1 Black RE, Morris SS, Bryce J. Where and why are 10 million children dying every year? Lancet 2003; 361: 2226–34. 2 Jones G, Steketee RW, Black RE, Bhutta ZA, Morris SS, for the Bellagio Child Survival Study Group. How many child deaths can we prevent this year? Lancet 2003; 362: 65–71. 3 Bryce J, Terreri N, Victora CG, et al. Countdown to 2015: tracking intervention coverage for child survival. Lancet 2006; 368: 1067–76. 4 Bhutta ZA, Chopra M, Axelson H, et al. Countdown to 2015 decade report (2000–10): taking stock of maternal, newborn, and child survival. Lancet 2010; 375: 2032–44. 5 Requejo JH, Bryce J, Barros AJ, et al. Countdown to 2015 and beyond: fulfilling the health agenda for women and children. Lancet 2015; 385: 466–76. 6 Victora CG, Barros AJ, Axelson H, et al. How changes in coverage affect equity in maternal and child health interventions in 35 Countdown to 2015 countries: an analysis of national surveys. Lancet 2012; 380: 1149–56. 7 Greco G, Powell-Jackson T, Borghi J, Mills A. Countdown to 2015: assessment of donor assistance to maternal, newborn, and child health between 2003 and 2006. Lancet 2008; 371: 1268–75. 8 Hsu J, Pitt C, Greco G, Berman P, Mills A. Countdown to 2015: changes in official development assistance to maternal, newborn, and child health in 2009-10, and assessment of progress since 2003. Lancet 2012; 380: 1157–68. 9 Arregoces L, Daly F, Pitt C, et al. Countdown to 2015: changes in official development assistance to reproductive, maternal, newborn, and child health, and assessment of progress between 2003 and 2012. Lancet Glob Health 2015; 3: e410–21. 10 Countdown Working Group on Health Policy and Health Systems, Cavagnero E, Daelmans B, Gupta N, Scherpbier R, Shankar A. Assessment of the health system and policy environment as a critical complement to tracking intervention coverage for maternal, newborn, and child health. Lancet 2008; 371: 1284–93. 11 Amouzou A, Habi O, Bensaïd K; Niger Countdown Case Study Working Group. Reduction in child mortality in Niger: a Countdown to 2015 country case study. Lancet 2012; 380: 1169–78. 12 El Arifeen S, Hill K, Ahsan KZ, Jamil K, Nahar Q, Streatfield PK. Maternal mortality in Bangladesh: a Countdown to 2015 country case study. Lancet 2014; 384: 1366–74. 13 Afnan-Holmes H, Magoma M, John T, et al, for the Tanzanian Countdown Country Case Study Group. Tanzania’s countdown to 2015: an analysis of two decades of progress and gaps for reproductive, maternal, newborn, and child health, to inform priorities for post-2015. Lancet Glob Health 2015; 3: e396–409. 14 Wollum A, Burstein R, Fullman N, Dwyer-Lindgren L, Gakidou E. Benchmarking health system performance across states in Nigeria: a systematic analysis of levels and trends in key maternal and child health interventions and outcomes, 2000-2013. BMC Med 2015; 13: 208. 15 Countdown Accountability for Maternal, Newborn and Child Survival: the 2013 update. Geneva. http://countdown2015mnch.org/ documents/2013Report/Countdown_2013-Update_noprofiles.pdf (accessed Oct 12, 2015). 16 Bhutta ZA, Chopra M. The Countdown for 2015: what lies ahead? Lancet 2012; 380: 1125–27.
www.thelancet.com Published online October 16, 2015 http://dx.doi.org/10.1016/S0140-6736(15)00527-9
Viewpoint
17
18
Global Strategy for Women and Children. Every Woman Every Child EWEC 2.0. http://www.everywomaneverychild.org/globalstrategy-2? (accessed Oct 12, 2015). Rasanathan K, Damji N, Atsbeha T, l Brune Driss M-N, Davis A, on behalf of the Every Woman Every Child Determinants of Health Working Group. Ensuring multi-sectoral action on the determinants of women’s, children’s and adolescents’ health in the post-2015 era: what can the updated Global Strategy do? BMJ 2015; 351: h4213.
19 20
UNICEF. Committing to Child Survival: a promise renewed. Progress Report 2015. UNICEF: New York, 2015. International Food Policy Research Institute. Global Nutrition Report 2015: Actions and Accountability to Advance Nutrition and Sustainable Development. Washington, DC: International Food Policy Research Institute, 2015.
www.thelancet.com Published online October 16, 2015 http://dx.doi.org/10.1016/S0140-6736(15)00527-9
3
Moving ahead: what will a renewed Countdown to 2030 for Women and Children look like? Zulfiqar A Bhutta, Mickey Chopra
The Countdown to 2015 initiative (Countdown) represents a remarkable consortium of academicians, UN agencies, and development partners, which over the past decade, has focused its attention on tracking and analysing coverage of key interventions for reproductive, maternal, newborn, and child health (RMNCH) across 75 high burden countries that account for more than 95% of global maternal and child deaths. Initially started to ensure follow-up on the landmark Lancet Child Survival series,1,2 with innovative consolidation and presentation of coverage data on key interventions by country and regions,3 Countdown rapidly evolved with an expansion of its mandate to include reproductive and maternal health indicators across the continuum of care4 and more recently, analysis of nutrition trends and health policies.5 Countdown is also an example of the collective power of champions, innovative scientific and collaborative work across academic groups, civic society organisations, and UN agencies and partnerships across various sectors. Elements that have worked include strong buy-in from the UN and development agencies and the legitimacy of Countdown analysis by countries. Important strengths of Countdown have included multidonor support, relatively flexible governance and technical structures, strong links to the Partnership for Maternal and Child Health, and more recently to the independent expert review group (iERG) of the UN Secretary General for monitoring MDGs 4 and 5. Countdown’s core work on monitoring and measuring coverage of key interventions to affect MNCH interventions across the continuum of care represents one the major sources of consolidated information that governments, development agencies, civic society organisations, and the iERG have used in their work. Some aspects of Countdown’s work have also been challenging especially financial dependence on a limited set of donors, perceptions of independence in view that much of its core funding flowed through UN agencies, slow devolution of technical work to the regions, and relatively low-key advocacy. The latter is also evidenced by a gradual transition from standalone Countdown meetings as was the case in 2005 and 2008 to more limited sessions and visibility in other global MNCH meetings since. The release of its final report and the adoption of a new set of global Sustainable Development Goals (SDGs) invoke the question of what next for the Countdown? There are several core features of Countdown that should be preserved as we move into the SDG era. The collation, presentation, and analysis of a core set of
metrics centred on the coverage of crucial lifesaving interventions remains pertinent and critical to continued monitoring of SDG 3 (ensuring healthy lives and promotion of well being for all at all ages). Countdown further developed a range of equity measures across wealth quintiles and other markers such as geography, sex, and ethnicity6 that will be important to retain and link to assessments of equitable impacts of universal health care on MNCH. Of late, the group’s foray into geospatial analysis of inequities represents a powerful set of instruments to affect policies and investments. These must underpin any future monitoring of progress and accountability. A core working group on health financing has monitored global resource flows with a specific focus on overseas development assistance for RMNCH and sequential assessments of financing.7–9 Additional analyses of health systems and policies have allowed insight into awareness within countries of evidence-based key interventions for RMNCH and subsequent policy development and implementation at scale.10 A major development in recent years has also been the conscious move to analyse factors determining RMNCH progress at national or subnational level. Examples of these Countdown country case studies include insightful analyses of progress in child survival in Niger,11 maternal health in Bangladesh,12 and progress across RMNCH in Tanzania.13 At least six further case studies are underway in a range of countries including Peru, Pakistan, Afghanistan, Kenya, and Malawi and have engaged local experts and institutions as well as regional collaborations. Despite other similar exercises more recently,14 Countdown remains the dominant global group making available to countries a wide range of technical, financial, and political support for multistakeholder capacity development for monitoring and evaluation. In view of Countdown’s regular inputs to the iERG in monitoring global progress in relation to Milennium Development Goals (MDGs) 4 and 5,15 it should continue with support to the newly proposed independent accountability panel for RMNCH. Multistakeholder partnerships, RMNCH focus, shift to regional and national support, and continued development of improved scientific methods will, we believe, keep the Countdown process relevant for the forthcoming SDG era.16 There is clear recognition of the need to address issues that go beyond mortality. The challenge would be to link the Countdown process to emerging issues, such as adolescent health and noncommunicable diseases without sacrificing the core mission of addressing RMNCH. The new global strategy
www.thelancet.com Published online October 16, 2015 http://dx.doi.org/10.1016/S0140-6736(15)00527-9
Published Online October 16, 2015 http://dx.doi.org/10.1016/ S0140-6736(15)00527-9 See Online/Review http://dx.doi.org/10.1016/ S0140-6736(15)00519-X Robert Harding Chair in Global Child Health and Policy, Centre for Global Child Health, Hospital for Sick Children, Toronto, ON, Canada (Prof Z A Bhutta PhD); Center of Excellence in Women and Child Health, The Aga Khan University, Karachi, Pakistan (Prof Z A Bhutta); and Lead Health Specialist, World Bank, Washington DC, USA (M Chopra MD) Correspondence to: Prof Zulfiqar A Bhutta, Centre for Global Child Health, Hospital for Sick Children, Toronto, ON M5G 0A4, Canada [email protected]
1
Viewpoint
for Every Woman Every Child (EWEC)17 along with the emergence of initiatives such as the Global Financing Facility (GFF) for RMNCH offers an opportunity to do exactly this and reach beyond the traditional health sectors to include social determinants of health.18 There is also the unique opportunity to link the EWEC and delivery strategies with core intervention coverage assessment and the equity agenda that Countdown has long espoused, and could well offer an approach to ensure that key evidence-based interventions and actions for the most marginalised women and children are not lost in the quest to address all sectors and determinants. With increasing capacity within agencies and the UN system, strategies such as the “Call to Action”19 and other groups undertaking analyses for monitoring and accountability,20 Countdown will be one of several sources of information for accountability for RMNCH within the SDGs, but aims to provide high value inputs and generate quality products. The three pillars of the new EWEC strategy17 include “survival” hence ending preventable maternal, child, and adolescent mortality, ensuring that all children and adolescents “thrive” and achieve their full growth and developmental potential and “transformation” of society to create a peoplecentred movement for sustainable change. Countdown will work with concerned agencies to help to develop an evaluation and analytical plan to monitor progress for this strategy. So what might the new Countdown to 2030 look like? Notwithstanding structural and organisational details, the refreshed Countdown should aim to link strongly to the principles of independent and robust accountability from the very outset with broad stakeholder support. Although Countdown should continue to maintain strong links with UN partners and bilateral funding agencies, its core principles of independence, scientific rigor, and work streams for technical improvements in measurement methods must be protected. In view of the need for moving to a country-focused monitoring and evaluation and advocacy agenda, Countdown should aim to function with much greater devolution to regions and key countries with a so-called hub and spokes model. These regional hubs will also serve to enhance and develop capacity within the countries for addressing RMNCH progress at not mere national level, but increasingly with subnational granularity and a focus on action and implementation. Countdown should continue to work closely with global agencies engaged in periodic household level surveys such as demographic and health or multiple indicator cluster surveys, to move away from mere monitoring of coverage to also embrace the concept of quality of care, and hence effective intervention coverage. Increasing focus on models for inclusion of findings from rigorous civic registration and vital statistics systems would improve the timeliness and local availability of information, and must be a strong theme for the future. 2
There will need to be enhanced focus on newer analytical methods and engagement of a new generation of academic bodies and leaders, especially in highburden settings, to ensure that the goals of the new EWEC initiative are achieved within the timeframe the world has set itself. Contributors ZAB and MC jointly wrote this Viewpoint and approved the final version. Declaration of interests ZAB and MC have been co-Chairs of the Countdown for 2015 coordinating committee since 2006 and 2009, respectively. These are honorary, non-remunerated positions. We declare no other competing interests. References 1 Black RE, Morris SS, Bryce J. Where and why are 10 million children dying every year? Lancet 2003; 361: 2226–34. 2 Jones G, Steketee RW, Black RE, Bhutta ZA, Morris SS, for the Bellagio Child Survival Study Group. How many child deaths can we prevent this year? Lancet 2003; 362: 65–71. 3 Bryce J, Terreri N, Victora CG, et al. Countdown to 2015: tracking intervention coverage for child survival. Lancet 2006; 368: 1067–76. 4 Bhutta ZA, Chopra M, Axelson H, et al. Countdown to 2015 decade report (2000–10): taking stock of maternal, newborn, and child survival. Lancet 2010; 375: 2032–44. 5 Requejo JH, Bryce J, Barros AJ, et al. Countdown to 2015 and beyond: fulfilling the health agenda for women and children. Lancet 2015; 385: 466–76. 6 Victora CG, Barros AJ, Axelson H, et al. How changes in coverage affect equity in maternal and child health interventions in 35 Countdown to 2015 countries: an analysis of national surveys. Lancet 2012; 380: 1149–56. 7 Greco G, Powell-Jackson T, Borghi J, Mills A. Countdown to 2015: assessment of donor assistance to maternal, newborn, and child health between 2003 and 2006. Lancet 2008; 371: 1268–75. 8 Hsu J, Pitt C, Greco G, Berman P, Mills A. Countdown to 2015: changes in official development assistance to maternal, newborn, and child health in 2009-10, and assessment of progress since 2003. Lancet 2012; 380: 1157–68. 9 Arregoces L, Daly F, Pitt C, et al. Countdown to 2015: changes in official development assistance to reproductive, maternal, newborn, and child health, and assessment of progress between 2003 and 2012. Lancet Glob Health 2015; 3: e410–21. 10 Countdown Working Group on Health Policy and Health Systems, Cavagnero E, Daelmans B, Gupta N, Scherpbier R, Shankar A. Assessment of the health system and policy environment as a critical complement to tracking intervention coverage for maternal, newborn, and child health. Lancet 2008; 371: 1284–93. 11 Amouzou A, Habi O, Bensaïd K; Niger Countdown Case Study Working Group. Reduction in child mortality in Niger: a Countdown to 2015 country case study. Lancet 2012; 380: 1169–78. 12 El Arifeen S, Hill K, Ahsan KZ, Jamil K, Nahar Q, Streatfield PK. Maternal mortality in Bangladesh: a Countdown to 2015 country case study. Lancet 2014; 384: 1366–74. 13 Afnan-Holmes H, Magoma M, John T, et al, for the Tanzanian Countdown Country Case Study Group. Tanzania’s countdown to 2015: an analysis of two decades of progress and gaps for reproductive, maternal, newborn, and child health, to inform priorities for post-2015. Lancet Glob Health 2015; 3: e396–409. 14 Wollum A, Burstein R, Fullman N, Dwyer-Lindgren L, Gakidou E. Benchmarking health system performance across states in Nigeria: a systematic analysis of levels and trends in key maternal and child health interventions and outcomes, 2000-2013. BMC Med 2015; 13: 208. 15 Countdown Accountability for Maternal, Newborn and Child Survival: the 2013 update. Geneva. http://countdown2015mnch.org/ documents/2013Report/Countdown_2013-Update_noprofiles.pdf (accessed Oct 12, 2015). 16 Bhutta ZA, Chopra M. The Countdown for 2015: what lies ahead? Lancet 2012; 380: 1125–27.
www.thelancet.com Published online October 16, 2015 http://dx.doi.org/10.1016/S0140-6736(15)00527-9
Viewpoint
17
18
Global Strategy for Women and Children. Every Woman Every Child EWEC 2.0. http://www.everywomaneverychild.org/globalstrategy-2? (accessed Oct 12, 2015). Rasanathan K, Damji N, Atsbeha T, l Brune Driss M-N, Davis A, on behalf of the Every Woman Every Child Determinants of Health Working Group. Ensuring multi-sectoral action on the determinants of women’s, children’s and adolescents’ health in the post-2015 era: what can the updated Global Strategy do? BMJ 2015; 351: h4213.
19 20
UNICEF. Committing to Child Survival: a promise renewed. Progress Report 2015. UNICEF: New York, 2015. International Food Policy Research Institute. Global Nutrition Report 2015: Actions and Accountability to Advance Nutrition and Sustainable Development. Washington, DC: International Food Policy Research Institute, 2015.
www.thelancet.com Published online October 16, 2015 http://dx.doi.org/10.1016/S0140-6736(15)00527-9
3