WHO Director-General assesses progress and challenges in women’s and children’s health

Dr Margaret Chan
Director-General of the World Health Organization

Opening remarks at the Fourth stakeholder meeting: Accountability for women’s and children’s health – now and in the post-2015 agenda
Geneva, Switzerland

14 January 2014

Colleagues in public health, development partners, representatives of sister agencies and civil society organizations, ladies and gentlemen,

Welcome to this fourth meeting of stakeholders as we continue our efforts to improve accountability for women’s and children’s health. I thank all of you for coming to Geneva. We have a good mix of perspectives, experiences, and contributions at many levels represented in this room.

We are at the midpoint in a time-bound process of improving accountability. This is a good time to take stock of where we stand, the lessons we have learned, and how we can institutionalize these lessons as the international community moves into the post-2015 era.

When I was asked to serve as a vice-chair for the Commission on Information and Accountability for Women’s and Children’s Health, I knew we were embarking on a journey into largely uncharted territory.

Accountability for resources and results has long been deeply desired, but rarely tackled in a rigorous and systematic way. I also knew that establishing an accountability framework specifically for women’s and children’s health would be an especially hard test case, perhaps even the hardest test case imaginable.

As we all know, maternal and child mortality cannot be brought down without addressing fundamental weaknesses in health systems that have been neglected for decades. Addressing accountability for women’s and children’s health means addressing long-standing problems with health infrastructures and services, inadequate numbers of appropriately trained and motivated staff, and the absence in most countries of reliable systems for civil registration and vital statistics.

Accountability means counting. Transparency is impossible in the absence of reliable data. It means improving the way donors and recipient countries work together, the way information is collected and used, and the capacity to track resource flows throughout the health sector.

It means ensuring equitable access to services, fair financing for care, and, as the independent Expert Review Group so clearly reminds us, high quality care that is person-centred, not intervention-centred.

I have visited countries that removed fees for maternal and child health services, saw an immediate surge in the use of these services, but did not see improved health, because the quality of care remained poor.

Last year, The Lancet published the largest study to date, coordinated by WHO, on severe complications and “near misses” in pregnancy. The study concluded that having life-saving interventions available in health facilities will not reduce maternal mortality in the absence of overall improvements in the quality of maternal care and emergency services.

These are just some of the challenges before us. During this meeting, you will be considering recommendations from the first two iERG reports. How much progress has been made in meeting recommendations from the first report? And how should we prioritize recommendations from the second report?

The Commission on Information and Accountability envisioned accountability as a cyclical process involving monitoring, review, and remedial action. We depend on the iERG to uncover problems and make recommendations for remedial action.

The iERG reports encourage all stakeholders to think in very concrete terms. What are the barriers that have slowed down progress? What tools are missing or underutilized? Which innovations can be seized and applied for immediate gains? The iERG has also given us some very useful guidance as we think about ways to institutionalize the lessons learned and maintain the momentum in the post-2015 era.

In my view, rigorous and independent mechanisms for accountability hold great promise as a way of spending resources wisely, honouring commitments, fine-turning programme strategies in line with evidence of results, maintaining the confidence of donors, and winning the support of parliamentarians and ministers of finance.

Also in my view, our joint work on accountability is a grand experiment. Can an accountability framework expedite progress? If ways can be found to get and use better information, will this start a chain of events, with better health outcomes as the endpoint? If the answer to these questions turns out to be “yes”, I believe that accountability will become a permanent feature on the development agenda.

The iERG reports have given us a good inventory of challenges and remedial actions. But I think we also have some things to celebrate, some good reasons to continue to build momentum. Stimulated by the Commission’s 10 recommendations, we are seeing some progress, and also some new ways of dealing with some very old and stubborn problems.

Of the 75 targeted countries, 70 have developed country accountability frameworks through a process which brings together government and donors and includes civil society, parliamentarians, and the media. More and more countries are introducing scorecards to track progress.

Some 53 countries have received full or partial catalytic funding to stimulate implementation of the recommendations. We have witnessed an upsurge in health sector interventions to track vital events, notably births, deaths, and causes of death.

Work on accountability has brought a shift from maternal death reviews to maternal death surveillance and response, an approach which aims to identify all maternal deaths and make each one a notifiable event. This new approach also investigates causes of death, paving the way for targeted interventions to prevent maternal deaths and improve the quality of care. More than 50 countries have adopted the new approach and are taking steps to implement it.

National eHealth strategies have been developed and mHealth solutions are being scaled up in more and more countries. But more needs to be done to tap the full power of innovations in information and communication technology.

The Commission’s recommendations have stimulated the use of National Health Accounts as a standard platform for tracking resource flows throughout the health sector. You will be hearing more about this today.

To better harmonize and coordinate funding streams and activities, a Steering Committee has been established. An investment framework was launched last November. Above all, accountability is becoming part of the mindset of donors and countries alike as commitment to mutual accountability takes root.

The latest iERG report describes the International Health Partnership Plus as “probably the most advanced and successful accountability tool for partners.” This meeting can also take guidance from IHP+ efforts to streamline and strengthen country systems for information and accountability, and the tools that have been developed for this purpose.

In my experience, countries want capacity, not charity. They want self-determination, and they want self-reliance. Self-reliance is by far the best exit strategy for development assistance.

Among its aims, IHP+ seeks to minimize the reporting burden on countries and strengthen country capacities by using and improving existing infrastructures and systems, not bypassing them with parallel single-purpose systems. As a recent IHP+ report concluded, countries have moved further in putting the principles of effective aid into practice than have their development partners.

The agenda for this meeting includes an opportunity to learn more about the IHP+ experience. The first meeting of the recently established Steering Committee for IHP+ coincides with this stakeholder meeting. We are most pleased that a joint session with the Steering Committee is scheduled for tomorrow.

As I said, this meeting is a good opportunity to take stock of where we stand. The number of deaths among young children has declined from 12 million in 1990 to 6.6 million in 2012. This is a stunning reduction of nearly 50%.

On the big-picture scale, this achievement tells us that targeted commitment and investments work. They do bring results. But they need to work much better, and in ways that ensure that gains are sustained.

What I hear from discussions with countries, partners, donors, and sister agencies is an overwhelming desire to do more. Recent striking declines in maternal mortality have opened up opportunities to do much more to reduce pregnancy and childbirth-related morbidities and, in many cases, disabilities that can ruin a young woman’s life.

I agree entirely with the latest iERG report. Doing so requires much more attention to the health and reproductive needs of adolescents and a human-rights based approach. It requires greater use of laws and policies as part of efforts to prevent early or forced marriage, address violence against young women, and remove barriers to family planning services.

The accountability framework placed accountability firmly at the country level, with the active engagement of national governments, parliaments, communities, and civil society organizations. The lion’s share of the credit for recent achievements must go to countries. Countries are the owners, and the leaders, of any efforts to improve the health of their women and children.

Donors and development partners must never forget that recipient countries absorb development assistance through a tremendous mobilization of their own, often very limited, resources for health. They deserve first say in how these resources are used. In some cases, donors and development partners are undermining already limited resources and capacity.

These stakeholder meetings have always produced useful guidance that has helped us move forward. During this meeting, we are concerned about ensuring that the current momentum continues to build, and that accountability frameworks become fully operational in a growing number of countries. We need to think about what needs to be done to support fragile states. We may need to create new models especially tailored to their needs.

In the interest of minimizing the demands on countries, we need to consider the feasibility of having a single accountability framework that links together and monitors the impact of a number of new initiatives, including the Commission on Life-Saving Commodities, the Global Vaccine Action Plan, and Family Planning 2020.

As you review the six recommendations from the iERG report, I would like to hear your ideas about which stakeholders should take the lead in following up on individual recommendations. I thank all stakeholders for their courage in embarking on a journey into largely uncharted territory, and for participating in what I consider to be a grand experiment with major implications for the future of public health.

Let me conclude with a success story that offers many lessons. It is also a source of inspiration. It reinforces the reasons why all of us are here, committed to improving the health of every woman and every child, and committed to using an accountability framework as an innovative tool for doing so.

In 2012, Niger surprised the world with a research paper, published in The Lancet, documenting striking reductions in child mortality. In Niger, one of the poorest countries in the world, child mortality was reduced by 43% between 1998 and 2009 through a government-led initiative, supported by donors. Compared with baseline data from 1990, child deaths dropped by a remarkable 65%.

As the latest iERG report has noted, the country’s ability to collect and use high-quality data was critical to this success. Quality of care was also important. The government built nearly 2000 community health posts, staffed with trained and paid health workers, and stocked with essential medicines.

User fees for children and pregnant women were abolished and use of services soared. Dramatic reductions in child mortality were seen across all income levels, in rural as well as urban areas, for girls and for boys.

In a commentary published together with the study, the Minister of Health expressed the enormous pride of the Government of Niger for having moved the country from its position in 1990, of having the highest child mortality rate in the world, to a current rate of annual decline that puts MDG 4 in reach.

The government made a deliberate decision not to wait for education to improve, or for poverty to go down, or for nutrition to get better. While all of these improvements are important, their achievement in a very poor country can take several generations. The estimated 59,000 lives saved in 2009 alone were considered proof of the value of immediate action.

This example shows the importance of building country capacity to gather and analyze data, of leadership at the highest level of government, of the significance of health achievements for national pride, and of donor support in a situation where the chances of success were by no means assured.

You will be hearing more success stories today and tomorrow. If the components of an accountability framework can bring success on this scale, public health does indeed have a powerful new tool for the future.

Thank you.