Towards Greater Accountability: Where Do We Go From Here?

Remarks by Kul Chandra Gautam·

At an interaction on Keeping Promises, Measuring Results

On Women’s and Children’s Health

New York, 23 September 2012

Having been personally involved in the founding of PMNCH and Countdown-2015 for maternal and child health, I am delighted to be here today to celebrate some of the great achievements made.

I join many others in congratulating Niger, and wish to share a quick personal reflection.

UNICEF started producing the State of the World’s Children Report in 1982 ranking countries according to their level of child mortality. For nearly 15 years, Niger consistently ranked as the country with the highest child mortality rate in the world.

Naturally, it became a test case, a great challenge for all of us trying to promote child survival, and claiming how great progress was possible.

I remember, starting in the mid-1980s UNICEF first doubled, then tripled and quadrupled its financial support to Niger. But its child mortality remained stubbornly high, as did malnutrition, illiteracy and other socio-economic indicators.

I am so glad that finally, Niger has turned the corner and is now being presented as a success story. If Niger can do it, any country can do it. Congratulations, again, Niger!

And let me refer to a second case which shows that money is important, but it is not decisive.

Last week, the UN published a report on MDG-8 which showed that in 2011 the biggest recipient of ODA in the world was Afghanistan. It got $6.3 billion in ODA last year, not counting almost a billion dollars a week of NATO’s expenditure in that country for over a decade.

But for several decades, Afghanistan consistently remained the country with the highest maternal and child mortality, and the lowest literacy and education indicators in all of Asia.

I am glad that Afghanistan too is now making some progress, but there certainly is little correlation with the money spent.

The three reports that were introduced here today – the Countdown-2015, the PMNCH report on Commitments to the Global Strategy for Women’s and Children’s Health, and the IERG report on Accountability for the Every Woman Every Child Initiative – give us a great sense of hope and momentum.

So does, I might add, the latest Progress Report by UNICEF and the Interagency Group on Child Mortality Estimation.

As we heard, since the launch of the Secretary-General’s Global Strategy for Every Woman Every Child two years ago, there has been a growing commitment to that strategy.

This year’s high-level events on the Child Survival: Promise Renewed and the Family Planning Summit in London have further reinforced these commitments.

Next week we will witness here at the UN two additional and supportive initiatives on Scaling Up Nutrition and Education First.

With all these high-level commitments, what we need now is a heightened sense of urgency and seizing the opportunity for action and results on the ground as we approach the 2015 milestone.

So where do we go from here?

Here at the UN, sovereign equality of all member states reigns supreme. We must respond to the unique situation of every country – their needs, their prospects, and their preferences.

We can see from the 3 reports that more action and support is needed in every country – whether donor or developing, large or small, middle-income or the least developed ones (LDCs).

But from a global perspective, achievement of the MDGs requires some sharper focus. And the 3 reports presented here show us the way forward.

The Countdown report asks us to focus on 75 countries that account for 95% of maternal and child deaths. The PMNCH and IERG reports drill these down to 49 of the world’s poorest countries that are priority for the Every Woman Every Child Initiative.

But if we look at the need and prospects for the biggest bang for the buck – I surmise from these reports the need for special priority action in 3 areas:

* the Top 10 countries with highest numbers of maternal and child deaths;

* the Top 10 countries with the highest rates of U5MR and MMR;

* and a special focus on the Top 10 direct causes of U5MR and MMR

Why focus on these three Top 10s?

I’d say for the same reason that the notorious American bank robber Willie Sutton said – when asked “why do you rob a bank?” – he answered: “Because that’s where the money is!”

The Top 10 countries with the highest child deaths (India, Nigeria, DRC, China, Pakistan, Ethiopia, Indonesia, Bangladesh, Uganda, and Afghanistan) account for 70 % of the world’s child deaths.

The Top 10 countries with the highest U5MR (Sierra Leone, Somalia, Mali, Chad, DRC, CAR, Guinea Bissau, Angola, Burkina Faso, and Burundi) plus a few others, that are among the poorest, post-conflict, and fragile states, mostly in Africa.

And the Top 10 causes of U5MR and MMR which include – the six leading causes of deaths among children – pneumonia, diarrhea, pre-term births and intrapartum complications, malaria, injuries and accidents cumulatively accounting for 65% of under-5 deaths; and the four leading causes of maternal mortality – hemorrhage, hypertension, unsafe abortion, and sepsis – cumulatively accounting for 70% of maternal deaths.

Add to these, malnutrition as the most important indirect cause of one-third of child deaths and one-fifth of maternal deaths, which we must address following the “Golden 1000 days” approach which has proven to be so effective.

And let me quickly and emphatically add that – as we all believe in prevention is better than cure – the vital importance of family planning – as 40 % of pregnancies world-wide are unintended – and reducing them would be tackling the problem at its root.

These would be the broad, headline interventions from a global perspective. But unlike some of us globe-trotters here, most people do not live on the globe – they live in individual countries and communities with their unique specificities. So there must necessarily be some additional country-specific interventions in all countries.

For example, there is now a great need and an opportunity to drastically reduce pediatric AIDS through effective PMTCT interventions, especially in high prevalence, low coverage countries. Thus the “Countdown to Zero” transmission of pediatrics AIDS must be an important component of the Every Woman Every Child initiative.

There are two other important lessons we gather from these reports:

a) all the essential interventions identified in these reports would be even more effective if they are pursued in a life-cycle manner as the “continuum of care” encompassing reproductive, maternal, newborn and child health interventions, and

b) experience now shows quite convincingly that a focus on increased coverage must explicitly include concern for equity to have lasting positive impact.

In an international forum like this one, it is natural for us to be concerned about funding and resources. Two years ago, it was estimated that an additional $88 billion over 5 years would be required to fulfill the goals of the Every Woman Every Child Initiative.

Of this, only about $20 billion has been raised so far. More funding support is therefore needed from both donors and developing countries.

But an important message from the reports today is not only we need more resources, but we also need better targeting of the allocation of those resources.

The multilateral donor community, INGOs, and private foundations must give more priority to what are called “donor orphans” or countries that are not popular with bilateral donors, and for those interventions that are not yet very popular or glamourous with the media and celebrities.

Sometimes, we do our noble cause a disservice when we present our case in too technical terms or with statistics that seem overwhelming – millions of deaths requiring billions of dollars. Such figures often frighten politicians faced with unlimited demands and very limited resources, and make them feel helpless.

We must instead highlight the compelling nature of the issues we advocate as very simple, low-cost, low-tech measures that can lead to dramatic improvements in the survival, health and development of mothers and children, which would be sure vote-getters for politicians in elections.

Think of the Kangaroo method of moms keeping their babies warm and alive that can prevent deaths of 450,000 babies. Think of ways to further promote breastfeeding or the simple act of hand washing with soap. Think of making low-cost but effective contraceptives more readily available or ensuring universal access to micronutirents and vaccines, and judicious availability of simple antibiotics or caesarean section delivery.

These are not rocket-science and will not bankrupt any country’s treasury.

Many of us were inspired by the late Jim Grant of UNICEF who had an unusual knack for convincing political leaders to take bold actions by presenting them with simple messages and compelling arguments to invest in child survival.

We need such communications skills more than ever before, as the global development agenda is getting more crowded, and the issues we are dealing with might not be as fashionable as climate change or cloud computing.

We must also be mindful and supportive of other contributing factors and social determinants of health – such as women’s status and girls’ education, water and sanitation, and overall push for poverty-reduction which have a huge impact not only in improving women’s and children’s health but sustaining the progress we make.

It goes without saying that we need to strengthen health systems and tackle the critical shortage of skilled health personnel in under-served communities as the building blocks without which much further progress is not possible.

Finally, we need to already start charting out what should be the priorities for women’s and children’s health beyond the current MDGs. As the UN has already started deliberating on the post-2015 development agenda, I hope that part of our next year’s reports will focus on that longer-term agenda.

I am sure we would all agree that the health and well-being of women and children must continue to command a central place in the next round of global development agenda.

Thank you.