Financing women’s, children’s, and adolescents’ health

Background to the global strategy

Launched in 2010 by the secretary general of the United Nations, the Global Strategy for Women’s and Children’s Health has fuelled efforts to deliver the UN millennium development goals. The Global Strategy and the Every Woman Every Child advocacy movement have promoted collective action, joint messaging, and effective partnerships.

By 2014 the strategy had gathered more than 400 commitments from more than 300 partners around the world, ranging from governments, civil society organisations, foundations, and academia to professional groups, businesses, and international organisations. The Partnership for Maternal, Newborn & Child Health has estimated that financial pledges to the strategy reached almost $60bn in 2011-15, 18% of which (almost $11bn) was contributed by 27 low income countries.7 Of the 20 largest pledges, several were represented by global partnerships, countries, foundations, non-governmental organisations, multilateral organisations, and the private sector.7 Disbursement of these pledged funds has grown steadily, and by May 2014 almost 60% ($34.2bn) had been disbursed. This figure relates to financial commitments only: in addition to these, many commitments made to the global strategy are not easily monetised, so potentially more has been committed than the numbers alone are showing.

Despite the global economic downturn, the world has remained resolute in its pledges to the Global Strategy for Women’s and Children’s health. Official development assistance disbursements for reproductive, maternal, neonatal, and child health has risen by an average of 11% a year.7 (The Muskoka method8 was used to calculate this figure.)

Although pledges to women’s and children’s health remain strong on the world stage, this has not necessarily been the case at the country level. Recent (2010 to 2013) data on health expenditure show that governments in 12 countries (Benin, Burkina Faso, Cambodia, Cote d’Ivoire, Democratic Republic of the Congo, Gambia, Niger, Sierra Leone, Tajikistan, Tanzania, Togo, and Uganda) are the smallest funding source for reproductive, maternal, neonatal, and child health, at 21% of overall funding in each country, whereas external resources contribute 30%.9 Although in some cases “aid fungibility” (use of aid in ways not intended by the donors when disbursing the funds) may have contributed to this, by crowding out government and private sector funding, it still leaves households as the main source of funding for reproductive, maternal, neonatal, and child health, at 49% of all expenditure in these countries.

Post-2015 financing framework: understanding the resources needed

As the world transitions from the UN millennium development goals to a post-2015 world of sustainable development goals, a considerable part of the agenda for reproductive, maternal, newborn, child, and adolescent health remains unfinished, despite the progress made so far.

The current need for resourcing highlights in a dramatic way the urgency of scaling up financing. Although this scaling up can be financed by countries’ expected economic growth (given that this growth will far exceed the estimated cost of financing health over the 2015-2030 period2), challenges lie ahead.

Challenges facing the financing landscape

The current gap in financing can be bridged only through dramatic increases from domestic and international sources and from both public and private sectors. However, over the next few years we expect big shifts in the global economic picture, in the health financing landscape, and more broadly in the development financing landscape.

Economic growth has the potential to provide considerable resources, but the transition of countries from low income to middle income status is often accompanied by widening inequities between rich and poor people and by insufficient prioritisation of health. Poor targeting, inadequate use of evidence, and fragmented financing reduce the efficiency of existing investments. The poor state of civil registration and vital statistics systems hampers the ability to monitor progress and base decisions on sound evidence. The lack of a skilled health workforce, particularly at the community level in many countries, robs health systems of their first line of preventive action and defence and also a crucial employment opportunity in poor communities.

An analysis conducted by the Bill and Melinda Gates Foundation shows that between 2014 and 2030 an estimated 41 countries are expected to graduate from the World Bank’s fund for the poorest countries, the International Development Association.10 Additionally, 15 countries are expected to graduate from the African Development Bank’s Africa Development Fund, 15 are expected to graduate from the Asian Development Bank’s Asian Development Fund, and as many as 38 are expected to graduate from the Global Alliance on Vaccines and Immunization.10 Such graduations can be welcomed as a sign of prosperity and progress but must also be managed carefully to ensure that citizens at the greatest risk are not left behind.

Experience has shown that this increased “funding for health” will not occur automatically: while in low income countries each percentage point increase in economic growth is associated with growth in government spending on health of more than one percentage point, in lower middle income countries the associated growth is less than half a percentage point.11 The effect of this smaller rise in spending is compounded by the fact that, as countries reach lower middle income status, development assistance for health begins to fall, as donors’ graduation policies start to take effect. These combined effects can create major challenges for countries, particularly given that they often come at the same time as the countries are dealing with other issues, such as decentralisation, a greater need to tackle inequity (including pockets of vulnerability), and a shift to a growing burden of non-communicable disease.

Five strategic shifts

We propose five strategic shifts in the financing landscape for women’s, children’s, and adolescents’ health in the post-2015 world.

Conclusions

The wide financing gap will not be bridged unless we completely re-imagine the way our various sources of financing for healthcare are organised—and will not be bridged through harmonisation alone, which is necessary but not sufficient. We need more creativity in examining the inter-relations between existing sources of funds.

We call for an unprecedented funding effort over the coming 5-10 years to finance the next phase of the Global Strategy for Women’s, Children’s and Adolescents’ Health and to bring to bear, in a collaborative fashion, the entire range of financing opportunities outlined here—domestic and international, public, and private—to accomplish this task. Agreements to close the overall gap would need to be discussed at a country level and included as part of the post-2015 overall monitoring framework.

Countries should seek to reap the full benefits and financial capabilities of the multilateral development banks, such as the World Bank Group, Inter-American Development Bank, African Development Bank, Asian Development Bank, and Islamic Development Bank. The emerging New Development Bank may also present an opportunity once it is up and running. Grant financing available from bilateral organisations such as the Global Fund to Fight AIDS, Tuberculosis and Malaria, Gavi (the Vaccine Alliance), UNITAID, and other pooled funds could complement the multilateral development bank platforms.

The financing mobilised so far in support of Every Woman Every Child, and the remarkable reductions in suffering and death that this has enabled, proves that success is possible. Now, we must reach even further and bring our collective will and creativity to bear, to finance not only a reduction in but an end to preventable child and maternal deaths by 2030, along with an end to the epidemics of HIV and AIDS, tuberculosis, and malaria.