Country perspectives on integrated approaches to maternal and child health: the need for alignment and coordination.

Abstract

The sustainable development goals (SDGs) and updated Global strategy for women's, children's and adolescents' health (2016-2030) call upon countries and the global community to transform health systems and society. (1,2) Additional investments in women's, children's and adolescents' health are essential to achieve the ambitious agenda that has been set. Support for nationally-identified reproductive, maternal, newborn and child health priorities needs to be better coordinated and new mechanisms, such as the Global Financing Facility, need to be used to expand domestic financing and attract additional resources. (3,4) The relevant global frameworks have to be translated into actions at the country level and, for this, the lessons learnt from previous engagement with individual countries may give useful guidance. The Reproductive, Maternal, Newborn and Child Health Fund was established in 2013 to support countries with the highest burden of preventable maternal and child deaths and help direct such countries towards millennium development goals (MDGs) 4 and 5 (to reduce child mortality and to improve maternal health by 2015). The fund's main aims were to provide catalytic resources to fill the critical gaps identified by countries and facilitate greater integration of financing and intervention programmes. At the time of the fund's launch, integration was complicated by the proliferation of multiple new initiatives under the Every Woman Every Child umbrella--e.g. A Promised Renewed, Family Planning 2020 and the United Nations (UN) Commission on Life-Saving Commodities, etc. (5) In 2013, under the stewardship of heath ministries and with the support of the H4+ partnership, UN agencies and partners, a country engagement process was outlined to identify implementation gaps across the reproductive, maternal, newborn and child health spectrum. The objectives were to improve the alignment and integration of partners and programmes and to provide catalytic support for prioritized gaps. Using the latest relevant national and subnational data, a situation analysis was conducted to evaluate progress and identify key bottlenecks. Demand for reproductive, maternal, newborn and child health was then evaluated so that the interventions and strategies needed to achieve MDGs 4 and 5 could be determined. In many cases, the priorities identified had already appeared in existing national plans. In-country dialogues with key stakeholders then identified opportunities to strengthen national coordination and alignment. Forward-looking resource mapping was used to assess the financial resources that were--or might become--available to support reproductive, maternal, newborn and child health from domestic and external sources. Finally, prioritized gaps were identified against which further resource alignment could take place and new funding--e.g. from the Reproductive, Maternal, Newborn and Child Health Fund--mobilized. The country perspectives that we present in this article (Table 1) come from the health ministries, civil society organizations and partner agencies from 16 countries in sub-Saharan Africa that collectively received over 180 million United States dollars from the Reproductive, Maternal, Newborn and Child Health Fund (Box 1 and Box 2). These perspectives were generated from a synthesis of facilitated group discussions that took place, among representatives from all 16 focus countries, during a week-long workshop in October 2015. (6) By 2016, a range of lessons had been learnt from this country engagement process. There was a lack of enabling environment. At country level, there was persistent confusion around the multitude of global and regional initiatives on reproductive, maternal, newborn and child health. This resulted in high transaction costs for ministries and duplication and fragmentation in financing and programming. Although there was a compelling global discourse and commitment to improving alignment, this was not always mirrored by actions on the ground. …