Source: The Lancet
By Paul C Webster
Is the Canadian Prime Minster’s billion dollar initiative for maternal, newborn, and child health failing to meet the standards it has urged on the rest of the world? Paul C Webster investigates.
For decades, detailed information about Canadian aid projects has rarely been made public without lengthy, often futile recourse to legal pressure. Accountability has mostly been a matter of trusting largely unverifiable official accounts. So it came as a surprise to Aniket Bhushan, an analyst with the North South Institute, an Ottawa-based group that closely tracks Canada’s CAN$4 billion annual international development budget, when the Canadian Government published an online list of projects for its $2·85 billion Muskoka Initiative for maternal, newborn, and child health. But as Bhushan began probing the newly published information about the Initiative, his hopes quickly turned to disappointment. Although the project list—which included some details on costs and results—represented a breakthrough of sorts, it was riddled with worrying gaps. “It seemed useful at first”, Bhushan explains, “but the numbers don’t line up. They are incomplete. I realised very quickly there was no point working with it.”
Canada’s partial turn toward foreign aid transparency—bittersweet as it has proven for analysts like Bhushan—can be traced directly to Canadian Prime Minister Stephen Harper, who first emerged as a champion for international maternal health during a 2010 summit with the heads of state for the G8 nations in Muskoka, a vacation area north of Toronto. In an initiative that helped deflect attention from the summit’s $1·1 billion price tag, Harper committed Canada to $1·1 billion in new spending for maternal and child health over the coming 5 years on top of $1·75 billion in existing Canadian commitments. As part of the Muskoka Initiative, Harper added, a further $4·5 billion in funding from other nations and private donors had been pledged.
It was a message that pleased many global health advocates; Harper’s conservative Christian power base liked the emphasis on mothers and children as well. To reassure some of its most ardently Christian supporters, the Harper government had previously terminated Canadian development support for abortion services, a move that not only contradicted domestic Canadian law but also the laws of most countries where Canada funds maternal health programmes, according to Sandeep Prasad, executive director, Action Canada for Population and Development.
In launching the Muskoka Initiative, Harper insisted it would not be another soon-to-be-abandoned exercise in G8 wishful thinking. “Accountability will be the key”, he stressed. “We’ve put increased emphasis on that.” To follow-through on this promise, Harper soon agreed to serve with Tanzanian President Jakaya Kikwete as co-chair of a Commission on Information and Accountability for Women’s and Children’s Health (COIA), established under UN auspices in late 2010. The new commission moved quickly. In May, 2011, just as Canadian aid officials began posting information about Muskoka Initiative projects on the internet—the COIA issued Keeping Promises, Measuring Results, a 31-page report calling for ten key reforms within startlingly short deadlines. For countries with high rates of maternal and child mortality, Harper and Kikwete recommended the establishment of vital statistics registries, adoption of common health indicators, development of national health information systems, and bolstered health spending review capacities, all before 2015. For donor and recipient countries alike, the COIA recommended that, by 2012, “compacts” be written between governments and development agencies to report expenditures, and that all countries establish transparent “national accountability mechanisms”. By 2013, the COIA wanted all stakeholders “publicly sharing information on commitments, resources provided and results achieved annually, at both national and international levels”.
As a final recommendation—in an effort to hold the world accountable for accountability itself—the Commission established an eight-member independent expert review group (iERG) to report to the UN. Perhaps not surprisingly, the iERG (which is co-chaired by Lancet editor Richard Horton) hasreported “checkered” results in many nations with high rates of maternal and child mortality, says Tarek Meguid, a physician based in Tanzania who serves as one of the group’s three Africa-based members. In its 2013 report, the group judged that “half of the recommendations are currently off track, meaning that they will be difficult or impossible to achieve by 2015”. The Commission’s deadlines “weren’t realistic”, says Dean Jamison, professor in Global Health Sciences at the University of California, who serves as the iERG’s sole American member.
Deadlines aren’t the only problem. Although the Commission estimated it would cost $96 million to implement its recommendations, much of this money has yet to materialise. “Transparency costs money”, Jamison explains. “Getting the numbers straight in a way that is accessible is hard work that takes trained people large amounts of time.” So far, only Canada, Germany, and Norway have contributed. At present—although more money may yet be found to help those countries that are implementing the COIA recommendations, according to Ties Boerma, director of the WHO Department of Health Statistics and Informatics—the iERG reports a shortfall of at least $50 million.
Whether the lack of financial support from donor nations for accountability on maternal health reflects a lack of commitment to accountability itself is a question worth asking, Jamison says. “It absolutely would have been better to have secured the funds up front. If the international system really placed a high priority on it, this would happen.”
Although the COIA mostly emphasised the need for reporting, transparency, and accountability in countries that receive aid, Jamison notes, its recommendations also apply to donor nations such as Canada.
In Ottawa, Aniket Bhushan and other Muskoka Initiative analysts believe the Harper government has failed to meet the standards its leader urged on the rest of the world. Jean Francois Tardif, national coordinator for Global Poverty Solutions, a research group that studies Canadian aid commitments, agrees with Bhushan that although the government’s own numbers indicate it may be meeting its commitments to the Muskoka Initiative, the government’s patchy transparency effort makes verification impossible. “You have to trust the powers that be”, says Tardif. “There is an issue of basic accountability in that I cannot reproduce the government’s figures.” Bhushan and Tardif both note that in the period since the launch of the Muskoka Initiative, the Harper government has slashed Canadian aid spending by roughly 20%—amounting to an estimated $800 million in 2013. Canadian aid as a percentage of gross national product is now among the lowest in the wealthy world.
The UN has expressed similar doubts about Harper’s accounting for international commitments to the Muskoka Initiative on its website addressing the initiative. Although the UN notes that $7·3 billion was pledged, it cautions that “it is not clear whether these commitments are additional to other ODA [overseas development assistance] and health commitments”.
Diane Jacovella, assistant deputy minister for Multilateral and Global Programs with the Canadian Department of Foreign Affairs, Trade and Development in Ottawa, says the Canadian Government is “attempting to make the information we have as available as possible”. The government’s Muskoka Initiative website “may not have all of the initiatives that we have in place”, she acknowledges. But Canada is “on track”, she avers, and has disbursed 80% of its Muskoka commitments. A full accounting for the Muskoka Initiative funds will be provided by 2017, she promises. “If the issue is are we committed to making the information available, we are.”
Financial opacity is not the only worry. According to a 2012 study led by Helen Scott, director of the Canadian Network for Maternal Newborn and Child Health (CAN-MNCH), which has received $1·8 million from the Muskoka Initiative to form a network including many Muskoka Initiative grantees, although Harper’s COIA specifically indicated that all countries and organisations should be collecting information about 11 key outcome indicators, only 36% of CAN-MNCH were collecting this information. “While all organisations reported being aware of most metrics reported in the COIA, very few were actually measuring their progress using these metrics”, Scott reported. “Indeed, only one third of organisations reported using any outcome measures to evaluate their program’s impact.” At the Department of Foreign Affairs, Trade and Development, Diane Jacovella acknowledges that progress here has been uneven: “This is one of the most difficult things in terms of getting people to agree on a small set of indicators, and consistently monitoring them.”
Nor have Canadian officials embraced the COIA’s recommendation that results be made fully public. When The Lancet requested outcome reports for five recently completed Muskoka Initiative projects described online, officials refused to release four of them, citing legal concerns. For the fifth project, no outcome report was prepared. “If it is confidential information”, explains Jacovella about the government’s refusal to release outcome reports on projects executed by third parties, “of course we can’t share it”. Nevertheless, she insists, “we do take accountability seriously. We don’t just talk about it”.