Background

Tracking aid flows helps to hold donors accountable and to compare the allocation of resources in relation to health need. With the use of data reported by donors in 2015, we provided estimates of official development assistance and grants from the Bill & Melinda Gates Foundation (collectively termed ODA+) to reproductive, maternal, newborn, and child health for 2013 and complete trends in reproductive, maternal, newborn, and child health support for the period 2003–13.

Methods

We coded and analysed financial disbursements to reproductive, maternal, newborn, and child health to all recipient countries from all donors reporting to the creditor reporting system database for the year 2013. We also revisited disbursement records for the years 2003–08 and coded disbursements relating to reproductive and sexual health activities resulting in the Countdown dataset for 2003–13. We matched this dataset to the 2015 creditor reporting system dataset and coded any unmatched creditor reporting system records. We analysed trends in ODA+ to reproductive, maternal, newborn, and child health for the period 2003–13, trends in donor contributions, disbursements to recipient countries, and targeting to need.

Findings

Total ODA+ to reproductive, maternal, newborn, and child health reached nearly US$14 billion in 2013, of which 48% supported child health ($6·8 billion), 34% supported reproductive and sexual health ($4·7 billion), and 18% maternal and newborn health ($2·5 billion). ODA+ to reproductive, maternal, newborn, and child health increased by 225% in real terms over the period 2003–13. Child health received the most substantial increase in funding since 2003 (286%), followed by reproductive and sexual health (194%), and maternal and newborn health (164%). In 2013, bilateral donors disbursed 59% of all ODA+ to reproductive, maternal, newborn, and child health, followed by global health initiatives (23%), and multilateral agencies (13%). Targeting of ODA+ to reproductive, maternal, newborn, and child health to countries with the greatest health need seems to have improved over time.

Interpretation

The increase in reproductive, maternal, newborn, and child health funding over the period 2003–13 is encouraging. Further increases in funding will be needed to accelerate maternal mortality reduction while keeping a high level of investment in sexual and reproductive health and in child health.

Funding

Subgrant OPP1058954 from the US Fund for UNICEF under their Countdown to 2015 for Maternal, Newborn and Child Survival Grant from the Bill & Melinda Gates Foundation.

Since 1990, maternal and child mortality rates have fallen by about half, with the largest reductions occurring since 2000. ¹ However, only a third of countries with the greatest mortality burden (the 75 Countdown priority countries) achieved Millennium Development Goal 4 (MDG 4; to reduce the mortality rate in children younger than 5 years by two-thirds between 1990 and 2015), and only 6% achieved MDG 5 (to reduce the maternal mortality ratio by three-quarters). ¹ Part of the mortality reductions achieved has been attributed to increased coverage of life-saving interventions. ² Although vaccination coverage and malaria intervention coverage have increased substantially, coverage of family planning and safe motherhood interventions remain inadequate, and wide inequalities in coverage persist. ¹ Availability of adequate financial resources is a factor enabling progress towards improved health outcomes, through funding quality health services. ^{3 ; 4 ; 5} In many low-income countries, donor funding represents a substantial share of health sector financing, amounting to an average of 33% of total health expenditure across all low-income countries in 2013. ⁶

As part of the Countdown initiative, we have tracked aid flows to maternal, newborn, and child health, reporting findings every 2 years since 2006. From its original focus on tracking aid flows to maternal, newborn, and child health, our resource tracking exercise extended in 2009 to include reproductive and sexual health (reproductive, maternal, newborn, and child health). Since we began tracking resource flows, the Institute for Health Metrics and Evaluation (IHME) has begun tracking development assistance to the health sector ⁷ and the Partnership for Maternal, Newborn and Child Health tracks aid to reproductive, maternal, newborn, and child health. ⁸ The resource flows project of the United Nations Population Fund (UNFPA) and the Netherlands Interdisciplinary Demographic Institute, tracking international population assistance, has been underway since 2002, ⁹ and the Organisation for Economic Co-operation and Development recently began requesting that donors report on a reproductive, maternal, newborn, and child health policy marker as part of their official reporting. Unlike other initiatives, we take a detailed approach to resource tracking, coding record by record with the use of project descriptions, based on a clear conceptual framework and coding scheme. This enables us to maintain a highly disaggregated classification of projects and to estimate the full value of resources benefiting reproductive, maternal, newborn, and child health, including a proportion of aid to the health sector, and to the humanitarian and other sectors. ^{10 ; 11 ; 12 ; 13 ; 14 ; 15 ; 16}

Research in context

Evidence before this study

We searched for published literature in Pubmed using the terms: global AND (“external funding” OR “resource tracking” OR “official development assistance”) AND (maternal OR reproductive OR child OR newborn) for the period 2003–2016. We also reviewed Institute of Health Metrics and Evaluation (IHME), Partnership for Maternal, Newborn and Child Health (PMNCH) and the United Nations Population Fund (UNFPA) and the Netherlands Interdisciplinary Demographic Institute (NIDI) reports on aid flows, downloaded from the IHME, WHO and Resource Flows project websites. Several estimates exist of official development assistance plus grants from the Bill & Melinda Gates Foundation (ODA+) to reproductive, maternal, newborn and child health, including the past publications of the Countdown project, two studies examining external funding to reproductive health in conflict-affected settings, and estimates from the Institute for Health Metrics and Evaluation, Partnership for Maternal, Newborn and Child Health and UNFPA/NIDI. Past Countdown publications have not previously included updated estimates of ODA+ from previous years.

Added value of this study

This study extends the analysis of ODA+ to reproductive, maternal, newborn and child health to include disbursements made in 2013, disbursements made in 2003–12 but reported later, and corrections to inconsistencies in coding over the whole period of the Countdown project. This has resulted in a complete dataset of ODA+ disbursements for reproductive, maternal, newborn, and child health for the period 2003–13, as reported to the Organisation for Economic Co-operation and Development creditor reporting system, allowing for the first time analyses of trends in complete ODA+ to reproductive, maternal, newborn, and child health for the full period.

Implications of all the available evidence

We found that ODA+ for reproductive, maternal, newborn, and child health increased alongside ODA+ to the health sector, and faster than overall increases in ODA+. Increases have been greatest for child health, mainly relating to immunisation, and reproductive and sexual health, primarily relating to HIV; increases for maternal and newborn health have been smaller. Targeting to health need seems to have improved among recipient countries, particularly from 2009 to 2013. Different tracking exercises give a wide range of estimates.

This study presents an overview of trends in funding to reproductive, maternal, newborn, and child health over the period 2003–13. Using data reported by donors in 2015, we provide estimates for 2013 and updated estimates for 2003–12, including complete trends in reproductive and sexual health, which had previously only been reported from 2009. We present global trends, focusing particularly on the 75 Countdown priority recipient countries, where over 95% of all maternal and child deaths occur, and assess trends in targeting to health need. ^{17 ; 18} We reflect on findings over the period 2003–13 and at the end of the MDG era, to inform accountability exercises related to the Sustainable Development Goals.

We downloaded official development assistance (ODA) disbursement data for the period 2003–13 from the creditor reporting system of the Organisation for Economic Co-operation and Development on Jan 7, 2015. We obtained data for disbursements made by the Global Alliance for Vaccines and Immunization (GAVI) for 2003–06 directly from GAVI as they were not available through the creditor reporting system (Mocova D, GAVI , personal communication). We tracked disbursements to all recipient countries (147 countries in 2013, plus 17 regional recipients and unspecified bilateral disbursements) from all donors reporting ODA disbursements to the creditor reporting system (64 donors in 2013) and from the Bill & Melinda Gates Foundation, which has reported disbursements to the creditor reporting system from 2009 onwards. Although we considered private grants rather than ODA, we included Bill & Melinda Gates Foundation grants in our analyses and we refer to ODA+ when reporting results that include these grants. Other official flows were excluded.