National leadership: driving forward the updated Global Strategy for Women’s, Children’s and Adolescents’ HealthBMJ 2015; 351 doi: https://doi.org/10.1136/bmj.h4282 (Published 14 September 2015) Cite this as: BMJ 2015;351:h4282
- C K Mishra, additional secretary and mission director, National Health Mission, Ministry of Health and Family Welfare, India,
- Joe Thomas, executive director, Partners in Population and Development,
- Rakesh Kumar, joint secretary, Reproductive, Maternal, Newborn, Child and Adolescent Health (RMNCH+A), Ministry of Health and Family Welfare, India,
- Trupthi Basavaraj, senior consultant, MSG Strategic Consulting, UK,
- A J James, honorary visiting professor, Institute of Development Studies, Jaipur, India,
- Anshu Mohan, programme manager, Adolescent Health and International Partnerships, Ministry of Health and Family Welfare, India,
- Shyama Kuruvilla, senior strategic adviser, Family, Women’s and Children’s Health, World Health Organization, Switzerland,
- S Basavaraj, managing director, MSG Strategic Consulting, India
- Correspondence to: C K Mishra
Targets, as one would expect, are easier to set than to achieve. At the end of this year the millennium development goals for reducing maternal and child mortality will remain unmet.1 While most maternal and child deaths can be prevented using proved cost effective interventions,2 a range of factors—from poor governance to the lack of a skilled health workforce—affect its delivery at scale. This is especially true for the poorest people in low to middle income countries (LMICs), where the burden is highest.
Not surprisingly, numerous calls have been made for effective leadership to prioritise women’s, children’s, and adolescents’ health needs and to accelerate progress. While this requires the presence of a committed leader, this alone is not enough. Institutions within and outside government are equally important: they help to sustain leadership, enable resilience to shocks, and further the achievement of development goals.3 4 This is the focus of our paper. Drawing on lessons learnt from LMICs, we highlight how national leadership can put the updated global strategy into practice.
The analysis presented here is underpinned by a conceptual framework (fig 1⇓), which builds on the World Health Organization’s health systems building blocks5 and the global investment framework for women’s and children’s health.2
We used two approaches to identify the guiding principles and enablers for national leadership in driving health outcomes. Firstly, we reviewed the literature to assess factors that impede the effective delivery of health interventions in LMICs and their solutions. Secondly, we held consultations with a range of stakeholders including senior political and administrative leaders on 25 and 26 February 2015 in New Delhi, India, to gain their perspective on why leadership matters, what makes it effective, and how it can be sustained.
A key outcome of the New Delhi consultations was an agreement on the conceptual framework.6 Every Woman Every Child also published a more detailed version of this paper for additional comments.
Recent analysis of success factors in 10 fast track countries showed that some LMICs have been able to accelerate progress despite low health budgets and considerable social and political challenges. These were Bangladesh, Cambodia, China, Egypt, Ethiopia, Laos, Nepal, Peru, Rwanda, and Vietnam—which, when the success factor studies started in 2012, were on track to achieve millennium development goals 4 and 5a. Although no standard formula exists these countries are moving ahead in three main areas to improve women’s and children’s health7:
Guiding principles: political vision and emphasis on human rights, alignment of development aid with country plans, and sustainability have helped these countries to mobilise resources and shape their health systems. For instance, Nepal’s policies on safe motherhood and neonatal health and gender are anchored in the principles of human rights.
Systematic adoption of evidence based or catalytic strategies: mobilisation of partnerships, effective planning, and the use of robust and timely evidence to inform decision making and enable accountability have contributed to the optimal use of resources in these countries.
Multisector progress: about half of the reduction in maternal and child mortality in LMICs since 1990 can be attributed to investments in sectors that influence health, such as education, gender parity, water, sanitation and hygiene, and alleviating poverty. While improving its health outcomes Egypt met its millennium development goal target to increase sustainable access to safe drinking water and basic sanitation, and Cambodia reduced poverty across its population by 60% from 2004 to 2011.
Good governance (including corruption control), a focus on value for money, and women’s political and socioeconomic participation were further identified as key enablers in improving women’s and children’s health.7 In Ethiopia, where mortality in under 5s declined by two thirds from 1990 to 2012, government reforms to reduce corruption and improve the efficiency of civil services have made a difference.8
Framework for applying the global strategy
The causes of poor health outcomes for women, children, and adolescents relate partly to wider constraints that affect health systems and, ultimately, access to services. These include bureaucracies’ failure to incentivise performance3 and a weak political and legislative framework that contributes to corruption9 and hinders accountability.
National leadership—political and administrative—can potentially tackle these wider constraints and pave the way for reform. It can set priorities, revisit the relative roles of stakeholders, and mobilise and harmonise efforts at the local government, health facility, and community levels. Stakeholders include the government, multilateral and bilateral funding partners, private sector, civil society and non-profit organisations, academic institutions, and the media.
To this end, we include a framework illustrating how the updated global strategy can be translated into practice (fig 1⇑). It highlights how national leadership can implement illustrative policies for future investment—including legislation, programmes, and allocation of funds required for implementing the updated global strategy2—in the context of each country. Of critical importance is the need to create an environment where the planning, delivery, and monitoring of services is aligned with the principles of human rights, gender parity, equity, and aid effectiveness and is informed by individual and community participation.
Both of these potentially require policy changes and measures to improve governance. However, given that today’s leaders have to navigate an increasingly complex landscape—where adversarial political systems, trust deficits, and competing interests all make the path to reform more challenging—the framework also identifies five key enablers for sustaining effective political and administrative leadership. Together, these make it more likely for essential health interventions to be scaled up in a way that is operationally, financially, and socially sustainable and also for health systems to respond to new challenges and opportunities. These enablers, along with options for their implementation, are set out below.
A close working relationship between political and administrative leaders, characterised by a set of shared values and bureaucrats with the autonomy to shape policy, has helped the progressive development of some countries—for example, in Botswana, whose top politicians are often former civil servants.10 Nevertheless, this approach is likely to be successful only with the political will and effective bureaucracy, where the relative roles of political and administrative leaders are well defined and adhered to. To this end, the following options may be considered:
Increasing women’s political participation: this can affect priorities and resource allocation. For instance, a study examining the implications of political reservations in village councils across two Indian states found that leaders invested more in infrastructure that dealt with their own gender’s needs.11 Similarly, in Rwanda, where 64% of parliamentarians are women, a gender policy informs planning processes.12
Selecting and promoting skilled administrative leaders: a key first step to improving governance is ensuring meritocratic recruitment through civil service examinations.13 Stability in government also requires systems for transparent performance management and succession planning.
Building capacity: a number of tools are available to increase leaders’ effectiveness. These include skill development and peer to peer learning initiatives, as well as devolution and decentralisation of power. However, the evidence on their impact has been mixed7 14; as such, identifying strategies must involve an analysis of the types of challenges facing leadership.
Country led national health plan
A country led, costed national health plan, including financing and aligned with local priorities and conditions, can help to improve the targeting of resources and communicate a shared understanding of “how to.” It can also provide a basis for holding leadership accountable. There are, however, a number of underlying challenges.15
Firstly, not all countries are convinced of the utility of a national plan (rather than a budget) and may view it primarily as a way of raising funds—and, where a costed national health plan is in place,15 there is some way to go before the fundamental principles of aid effectiveness can be met.
Secondly, there is inadequate capacity to develop appropriate and flexible plans, as well as limited engagement of civil society in health policy formulation. Thirdly, disaggregated data including a breakdown of costs are lacking, and there is insufficient emphasis on procedures for mutual accountability. Fourthly, requirements of funding agencies, such as financial and procurement systems, are often not factored in and can lead to inefficiencies and misallocation of funds.
Development of the national plan would require appropriate guidelines based on global good practices, training, and analytical tools to determine resource allocation; advocacy and consultation with stakeholders to ensure buy-in and alignment; a shift towards pooled financing; a framework for measurement and accountability; and a country coordinating mechanism led by the national government.
Partnerships offer leaders a vehicle for aligning interests and using additional resources, plugging gaps and improving service delivery, developing and distributing low cost public goods, and fostering greater accountability. Their success, however, depends on whether leaders are “credible brokers” who can help to change perspectives while empowering weaker sections of society.16 Other factors include clear goals, standards, and processes governing transactions between stakeholders,17 as well as investment in technical knowledge and performance management.18
Perhaps one of the most important ways to ensure effective leadership is through appropriate monitoring and course correction at each level. While most countries will have a framework for enabling accountability, this can be strengthened19 by clearly defining financial and administrative authority; making disaggregated data and information on initiatives publicly available; strengthening judiciary and autonomous regulatory mechanisms to provide oversight; ensuring whistleblower policy and protection; and engaging better with stakeholders to independently monitor implementation.
Advocacy and collective action
Stakeholders outside the government can make sure that they fulfil their obligations.4 20 For instance, once the Turkish government had ratified the United Nations Convention on the Elimination of all Forms of Discrimination Against Women, the women’s rights movement successfully campaigned for a new civil and penal code.21 Key principles for effective advocacy22 23 include prioritisation and alignment of action; identification of evidence based strategies and “government champions”; engagement at every level, including individuals, communities, and religious leaders; and monitoring outcomes and impact.
Achieving the updated global strategy requires strong political commitment and collaborative governance. Although no universal blueprint exists, in countries with high maternal and child mortality rates efforts must be directed towards increasing the capacity, skill, and accountability of leaders. Ultimately, the health and wellbeing of women, children, and adolescents relies on how countries sustain effective political and administrative leadership.
Wider institutional deficiencies can affect the delivery of services for women, children, and adolescents
National leadership can set priorities and pave the way for reform—but, to achieve the updated global strategy, it must be sustained and effective
To scale up essential health interventions and create resilient health systems, political commitment must be supported by investment in country led health planning, management capacity, partnerships, accountability, advocacy, and collective action at all levels
Cite this as: BMJ 2015;351:h4282
Contributors and sources: The National Leadership working group for the updated Global Strategy for Women’s, Children’s and Adolescents’ Health developed, guided, and contributed to this paper. SB, TB, SK, AJJ, and AM were the core drafting team. SB and TB also ensured that relevant feedback from the consultations for the UN secretary general’s Global Strategy on Women’s, Children’s and Adolescents’ Health and from the online consultation were incorporated into the draft. All have read and agreed to the final version. CKM is guarantor.
Conflicts of interest: We have read and understood BMJ’s policy on declaration of interests and have no relevant interests to declare.
The authors alone are responsible for the views expressed in this article, which does not necessarily represent the views, decisions, or policies of WHO or the institutions with which the authors are affiliated.
Provenance and peer review: Not commissioned; externally peer reviewed.
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