Title: Global Mapping Exercise of Canadian Maternal, Newborn and Child Health Initiatives
Authors: Scott, H., Ph.D.1,2, McCarney, R.A. LLB, MBA,1,3 Shaw, D.,MBChB, FRCSC1,4,5
1.
Canadian Network for Maternal, Newborn and Child Health, Canada
Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario
3.
Plan International Canada, Toronto, Ontario
4.
University of British Columbia and BC Women’s Hospital & Health Centre, Vancouver,
British Columbia
2.
Corresponding Author
Dr. Helen Scott
Director, Canadian Network for Maternal, Newborn Child Health
Dalla Lana School of Public Health, University of Toronto
171 Shamrock Road, Omemee, ON K0L 2W0
Email: hscott@hollandbloorview.ca
PLEASE NOTE THAT THIS PAPER HAS BEEN ACCEPTED FOR PUBLICATION IN
THE JOURNAL OF OBSTETRICS AND GYNECOLOGY OF CANADA AND CANNOT
BE PRESENTED ELSEWHERE AT THIS TIME (JUNE 2012).
1
ABSTRACT
Objective: Accomplishing the ambitious targets set by the United Nations Global Strategy to
save the lives of 16 million women and children in low income countries by 2015 requires that
governments, development partners, civil society, academics and the corporate sector create new
partnerships and collaborations. The Canadian Network for Maternal, Newborn and Child Health
was a pilot initiative to determine possible synergies between Canadian organizations. The main
purpose of this project was to develop an online, up-to-date, interactive tool that examines the
nature, scope and type of Canadian MNCH (maternal, newborn and child health) activities and to
promote collaborative efforts among Canadian organizations. Methods: Relevant Canadian
organizations and institutions were identified and invited to complete a survey/ mapping exercise
if they were based in Canada and currently engaged in MNCH programming in low income
countries. Google Maps was used to portray MNCH-related activities world-wide, including
detailed descriptions of each initiative. Results: As of November 2011, 42 Canadian
organizations were identified that were engaged in 102 MNCH-related initiatives, in more than
1,000 regions in 94 countries. The results of this survey are summarized here and have been
shared in more detail through an interactive website mapping tool (www.canmnch.ca). Conclusion: The mapping exercise of in-country programs represented visually in an
interactive website has laid the groundwork for the Canadian Network for MNCH to facilitate incountry collaboration, share knowledge and success stories and build more robust mechanisms
for monitoring and accountability.
2
INTRODUCTION
Poor maternal, newborn and child health remains a significant problem in developing
countries. Annually, throughout the world, it is estimated that 358,000 women die during
pregnancy and child birth (1), and 7.6 million children die under the age of five (2). Maternal
deaths occur most commonly due to haemorrhage, pre-eclampsia/eclampsia, obstructed labour,
and infections and unsafe abortions (1). Approximately 40% of under-five deaths occur during
the first 28 days of life; half of all newborn deaths occur in the first day of life and 75% occur
with the first seven days. The primary causes of neonatal death are preterm birth, severe
infection and asphyxia. The tragedy of these deaths is that we have the knowledge and
technology to prevent them. Children in developing nations are almost 18 times more likely to
die than those in developed countries (2).
Of the eight Millennium Development Goals (MDGs), the two that focus on improving
the health of women and children (MDGs 4 and 5) (Table 1) are the furthest from being achieved
by 2015. As recently reported by Lorenzo et. al, (2011), sub-Saharan Africa and Southern Asia
continue to have the highest maternal, neonatal and under-five mortality rates (3). Although
many lower income countries are not on track to meet these goals, promising progress is being
made. Over the past 20 years, there has been a steady decline of about 33% in child deaths from
an estimated 11.9 million in 1990 to fewer than 8 million in 2011 (2). Estimates suggest the
number of women dying in childbirth fell by about 30% from over half a million in 1990 to
about 350, 000 in 2011 (1). Efforts are set to accelerate. In September 2010, the Global Strategy
for Women’s and Children’s Health (Global Strategy) (4) was launched at the United Nations
(UN) General Assembly. The main objective of the Global Strategy is to save 16 million lives by
2015 in 49 of the poorest countries. To this end, it has garnered commitments of over $40 billion
3
from governments, donors, non-governmental organizations, private sector, health professionals
and academics around the world.
Canada has taken a leadership role in mobilizing global action to improve the health of
women, newborns and children and to reduce the number of preventable deaths in the world’s
poorest nations through the Muskoka Initiative. The Canadian government has committed to
providing $1.1 billion in new funding between 2010 and 2015. Canada is also providing
$1.75 billion in ongoing spending on maternal and child health programming, a total contribution
of $2.85 billion. In November 2010, the Honourable Minister of International Development,
Beverley J. Oda, defined how Canada’s contribution to the Muskoka Initiative was organized
through the Canadian International Development Agency (CIDA), following three integrated
paths (support national health systems, fill gaps in health systems and expand access to services),
focusing on ten countries, and involving multilateral, global and Canadian partners (5).
Accountability for financial resources is central to the Global Strategy. To this end, the
UN Secretary General asked the Director General of the World Health Organization to determine
the most effective process for global reporting, oversight and accountability. Chaired by Stephen
Harper, Prime Minister of Canada and H E Jakaya Mrisho Kikwete, President of the United
Republic of Tanzania, the Commission on Information and Accountability for Measuring Women
and Children’s Health (COIA) (6), outlined 10 key recommendations and 11 core indicators on
health outcomes and coverage. Meeting these recommendations and accomplishing the
ambitious targets set by the Global Strategy requires that governments, development partners,
civil society, health professionals, academics and the corporate sector create new partnerships
and collaborations.
4
Why a Canadian Network?
Within the context set by the ambitious Global Strategy and the COIA, in November
2010, the Honourable Minister of International Cooperation, Beverley J. Oda, hosted the First
Roundtable on the Muskoka Initiative, attended by leaders from Canadian organizations involved
in maternal, newborn and child health (MNCH). Subsequently, at the Minister’s request, Dr.
Dorothy Shaw (Canada Spokesperson for G8/G20, Partnership for MNCH, Geneva) and
Rosemary McCarney (President and CEO, Plan International Canada, Inc.) agreed to coordinate
the establishment of a Canadian Network for MNCH (CAN-MNCH). CAN-MNCH was a pilot
initiative to determine possible synergies between different Canadian constituents, in order to
facilitate integration across Health MDGs.
This pilot initiative, funded by CIDA, was comprised of three phases:
Phase 1: The first phase (mid- 2011) involved surveying potential Network Partners and
developing an appropriate web-based interface, through a mapping exercise of MNCH-related
activities in current CIDA-focus countries and relevant global activities overall. These results are
shared on the website www.can-mnch.ca. The results of the mapping exercise are reported in the
present paper.
Phase 2: The second phase (late 2011) involved consulting Network Partners on the level of
support for creating a Canadian MNCH network and determining their unique value
contribution.
Phase 3: The focus of the third phase (early 2012) was to begin discussions on developing and
contributing to a limited, common set of MNCH metrics for tracking and evaluating activities incountry, with comparability for Network Partners. These metrics will be developed through
5
consultation with all Network Partners, and aligned with recommended metrics in the report
from the COIA.
METHODS
One of the first tasks of the Network was to develop a portrait of the programs and
initiatives being provided by Canadian organizations to save the lives of women and their
children and to improve maternal, newborn and child health around the world.
The CAN-MNCH Activities Survey was developed based on discussions from the First
Ministerial Roundtable on the Muskoka Initiative and input from various stakeholders. The first
section of the Activities Survey requested potential Network Partners to identify the countries
where they are engaged in MNCH initiatives aimed to address the Millennium Development
Goals 1c, 4, 5, and 6 (Table 1). The second section asked the potential Network Partners to
answer a series of questions about each of the organization's MNCH-related initiatives.
Potential Network Partners were identified and contacted between May and September
2011. These included organizations, academics and health care professionals who attended the
first Ministerial Roundtable on the Muskoka Initiative and others identified through personal
communication with relevant stakeholders and online searches.
Potential Network Partners were asked to complete the online Activities Survey if they
were based in Canada and currently engaged in in-country, MNCH-related work. Survey results
were the basis for the mapping exercise of MNCH-related activities. The results are summarized
in the present paper and have been shared with all Network Partners, CIDA and more broadly
through an interactive website mapping tool (www.can-mnch.ca).
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Results
Thirty-one (31) participants from the first Ministerial Roundtable on the Muskoka
Initiative were invited to participate in the Network. Of these, five organizations were not
currently engaged in in-country work, but expressed interest in being involved with CANMNCH as a Resource Partner. Twenty one (21) organizations completed the Activities Survey/
Mapping Exercise. Fifty-two (52) additional organizations were identified and invited to
respond. Twenty-one (21) completed the Activities Survey and twenty (20) are not currently
engaged in MNCH-related initiatives. Eleven did not respond.
Where are Canadians working?
As of November 2011, there were 42 Network Partners, engaged in 102 MNCH-related
initiatives, in more than 1,000 regions in 94 countries around the world. More than 80% of
Canadian MNCH initiatives have been in working these country regions for more than 5 years.
Table 2 shows the number of in-country MNCH initiatives in each of the 94 countries. It should
be noted that not all initiatives have equal weight in terms of scope, target population and
outcome, so counting the number of initiatives as a measure of the intensity of Canadian work
within a country may not provide an accurate portrayal of Canadian work in-country. Countries
with the highest number of Canadian MNCH-related initiatives include Ethiopia (22), Uganda
(21) and Tanzania (17).
Approximately one quarter (10) of the Network Partners are currently engaged in MNCH
activities in only one country. Slightly more than half (25) of the Network Partners reported that
they were working in between two to four countries and four organizations worked in more than
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ten countries. The responses of three organizations were not included because the project had
recently ended for one organization and the data was incomplete for two others.
More detailed information about where about where Canadians are engaged in MNCHrelated activities can be found at www.can-mnch.ca.
What are Canadians doing?
Network Partners are engaged in 102 different initiatives, many of which are
implemented in multiple regions in-countries. As shown in Figure 1, responses to the Activities
Survey indicate that training local community workers and health education programs are the
most common type of MNCH-related activities, followed closely by training health care
professionals and health systems strengthening. Conducting research and policy development
were reported as the least common activity.
Not surprisingly, most (63) initiatives were targeted toward women, newborn and
children. Only three initiatives targeted women exclusively and 12 targeted newborns. Twenty
initiatives were targeted at populations with specific diseases, most often HIV/AIDS. As shown
in Figure 2, Canadian MNCH initiatives are delivered by a wide range of workers. Most
initiatives are delivered by a combination of Canadian and international workers and paid and
volunteer workers. ‘Other’ workers include community leaders, donors, foundation members and
local university faculty members.
Network Partners are working with multiple agencies and organizations on the initiatives
around the world (Figure 3). The most common collaborating partner is with in-country
Ministries of Health (55%) followed by other Non-Governemental Organizations in-country
8
(49%). Note that the percentage is for each type of partnership and not for the figure as a whole,
since most organizations reported multiple partnerships.
Most organizations reported multiple funding sources for their programs. Almost half
(49) of the initiatives were funded by the Canadian International Development Agency (CIDA).
Twelve were funded by an in-country agency, 23 were funded by a Canadian agency and eleven
were funded by a United Nations agency. Fifty-three initiatives were funded by other sources.
Network Partners were asked to describe three key indicators for each initiative. Almost
two thirds (64%) of these were process measures. As shown in Figure 4, process measures
include training health care workers, training community workers and improved knowledge
about nutrition and other health issues. Research outputs included publications, grants and
knowledge dissemination. A wide range of ‘other’ measures were collected, such as program
coverage, percentage of supplies received by due date, and quantity of medication administered.
Although the COIA specifically indicates that all countries and organizations should be
collecting information about 11 key outcome indicators, only 36% of Network Partners reported
that they were collecting these (Figure 5). Mortality (under 5 years of age and maternal) and
skilled birth attendants were the most likely COIA indicators to be measured. This highlights an
important area of focus for the Network.
DISCUSSION
The present report provides a snapshot of the information gathered through the CANMNCH Activity Survey/ Mapping Exercise. The website, www.can-mnch.ca, presents more
detailed descriptions of the MNCH initiatives in 94 CIDA Focus, Global Strategy priority, and
other countries. As well as a brief description of the programs being offered in-country, and the
region where the organizations are working, the website also provides information about
9
program objectives, evaluation metrics, descriptions of target population, in-country workers and
links for more information about the program.
In addition to being a tool to connect Canadian constituencies abroad, this exercise
highlights a number of important issues. Firstly, although advocacy work has been collaborative
across diverse stakeholder groups for several years, joint in-country programming between NonGovernmental Organizations (NGOs) and Canadian health professionals and academics has been
less frequent. Network Partners have begun discussions in key countries of CAN-MNCH focus
with local partners working on MNCH issues and offered assistance for them in starting their
own national networks for information sharing, development, etc. CAN-MNCH provides an
opportunity for synergistic relationships to be built.
Secondly, while all organizations reported being aware of most metrics reported in the
COIA, very few were actually measuring their progress using these metrics. Indeed, only one
third of organizations reported using any outcome measures to evaluate their program`s impact.
More than two thirds of key evaluation measures were process measures (such as number of
health care workers trained, number of members in an association). While these process
assessments are important components of evaluation, they should not be the exclusive measure
of the success of particular programs. The Network can play a leadership role in identifying
strategies that facilitate and enhance alignment with the COIA, common reporting and effective
in-country programming. This may require some adjustment to funding proposals, grants and
project budgets to ensure such expectations are appropriately resourced.
The mapping exercise is intended to be a forum to bring Canadian organizations together
to improve our efforts at meeting the Health MDGs - specifically saving the lives of women and
children. It is a platform to launch synergistic activities in Canadian organization’s combined
10
efforts at meeting these goals. As described, Canadians are doing exceptional work around the
world to make a difference in the lives of women and children. Additional partners of the
Network and new initiatives for existing partners will be added going forward, enriching the
available information. It is envisioned that Network Partners will also meet annually to
determine areas of common focus where more in-depth technical expertise would be valuable.
The first such meeting occurred in November 2011, in conjunction with a Ministerial Roundtable
on MNCH where the results of the mapping exercise were presented to all the Network Partners
and to CIDA.
CONCLUSION
The creation of a Canadian Network for MNCH through a mapping exercise of in country
programs represented visually in an interactive website has laid the groundwork to facilitate incountry collaboration, share knowledge and success stories and build more robust mechanisms
for monitoring and accountability. The visual impact of the significant number of global
initiatives to save the lives of women and children and improve their health is remarkable and
demonstrates the significant Canadian contribution. There is already some indication of the
potential to accomplish more through working collaboratively and the leadership of Canada
could be instrumental in replicating such efforts more broadly.
ACKNOWLEDGEMENTS
This project was undertaken with the financial support of the Government of Canada provided
through the Canadian International Development Agency (CIDA).
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REFERENCES
1. Trends in Maternal Mortality1990 to 2008. Estimates developed by WHO, UNICEF,
UNFPA and The World Bank. World Health Organization 2010, Geneva, Switzerland.
2. Levels & Trends in Child Mortality. Report 2011. Estimates Developed by the UN
Interagency Group for Child Mortality Estimation. United Nations Children’s Fund,
2011. New York, New York, USA.
3. Lozano R, Wang H, Foreman KJ, Rajaratnam JK, Naghavi M, Marcus JR, DwyerLindgren L, Lofgren KT, Phillips D, Atkinson C, Lopez AD, Murray CJL. Progress
towards Millennium Development Goals 4 and 5 on maternal and child mortality: an
updated systematic analysis. The Lancet 2011;378(9797):1139–1165.
4. Global Strategy for Women’s and Children’s Health. United Nations. 2011. New York,
New York, USA.
5. acdi-cida.ca [Internet]. Ottawa: Canadian International Development Agency; [updated
2011; cited 2012 Feb 12]. Available from: www.acdi-cida.gc.ca
6. Keeping Promises, Measuring Results. Commission on Information and Accountability
for Women’s and Children’s Health. World Health Organization. 2011. Geneva,
Switzerland.
12
Table 1. Select Health Millennium Development Targets
1c: Halve the proportion of people who suffer from hunger
4: Reduce by two-thirds, between 1990 and 2015, the under-five mortality rate
5a: Reduce by three quarters, between 1990 and 2015, the maternal mortality ratio
5b: Achieve, by 2015, universal access to reproductive health
6a: Have halted by 2015 and begun to reverse the spread of HIV/AIDS
6b: Achieve, by 2010, universal access to treatment for HIV/AIDS for all who need it
6c: Have halted, by 2015, and begun to reverse the incidence of malaria and other major diseases
Source: www.un.org/millenniumgoals/ (accessed Feb. 22, 2012)
13
Table 2. Number of Canadian, In-Country Maternal, Newborn and Child Health Initiatives, 2011
Country
#
Country
#
Country
#
Country
#
Country
#
Afghanistan*
6
DR of Congo
5
Kiribati
1
Nicaragua
7
Sudan*
9
Angola
1
DR of Korea
2
Kyrgyz Republic
1
Niger
4
Swaziland
1
Azerbaijan
1
Ecuador
1
Kyrgyzstan
1
Nigeria
6
Tajikistan
1
Bangladesh*
12
Egypt
1
Laos
3
Pakistan*
10
Tanzania*
17
Benin
2
El Salvador
2
Lesotho
1
Palestinian Territories
1
Thailand
1
Bolivia*
6
Ethiopia*
22
Liberia
2
Papua New Guinea
1
The Gambia
1
Botswana
1
Fiji
1
Madagascar
1
Paraguay
2
Timor Leste
2
Brazil
2
Gabon
1
Malawi
8
Peru*
3
Togo
2
Burkina Faso
10
Ghana*
10
Mali*
9
Philippines
2
Turkey
1
Burundi
3
Guatemala
7
Marshall Islands
1
Romania
1
Turkmenistan
1
Cambodia
6
Guinea
2
Mauritania
2
Rwanda
5
Uganda
21
Cameroon
3
Guinea-Bissau
2
Mexico
1
Sao Tome & Principe
1
Ukraine*
1
CEE/CIS regional
1
Haiti*
8
Micronesia
1
Senegal*
13
Uzbekistan
2
Central African
Rep
1
Honduras*
2
Moldova
1
Serbia
1
Vietnam*
3
Chad
2
India
12
Mongolia
1
Sierra Leone
5
West Bank and Gaza*
1
China
6
Indonesia*
7
Mozambique*
10
Solomon Islands
1
Yemen
1
Colombia*
2
Israel
1
Myanmar
1
Somalia
1
Zambia
7
Côte d'Ivoire
2
Kazakhstan
1
Namibia
1
South Africa
8
Zimbabwe
6
Dominican
Republic
2
Kenya
16
Nepal
4
Sri Lanka
3
Afghanistan*
6
DR of Congo
5
Kiribati
1
Nicaragua
7
* CIDA-focus countries; BOLD TEXT – 20 countries with highest number of initiatives
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Figure 1. Type of Maternal, Newborn and Child Health Activities
*Network Partners may be engaged in more than one activity
Other
Policy development
Research
Knowledge translation
Advocacy
Nutrition
Healthcare service delivery
Health system strengthening
Training Health Care Professionals
Health education programs for target population
Training local community workers
0
20
40
60
80
Percentage of Initiatives
15
Figure 2. Who Delivers In-Country Initiatives
*Initiatives may be delivered by more than one group
Other
International, Volunteer
International, paid
Local population, volunteer
Local population, paid
Canadians, volunteer
Canadians, paid
0
10
20
30
40
50
60
70
80
Percentage of initatives*
Figure 3. Who are Network Partners Collaborating with
on MNCH Activities
*Network Partners may collaborate with more than one organization
Other
Other in country governmental agencies
Organization's International Association
Ministry of Health
Ministry of Education
Academic institution in Canada
Academic institution in country
Health Professional Organization, in Canada
Health Professional Organization
Non-Governmental Organizations in Canada
Non-Governmental Organizations in country
United Nations agency, International
United Nations agency in country
0
10
20
30
40
Percentage of initiatives*
50
60
16
Figure 4. Types of Process Measures Collected
Other
Training community workers
Research output
Organizational capacity
Knowledge change
Access to health care
Training health care professionals
Improved nutrition
0
10
20
30
40
Number of initiatives
Research outputs includ
as program coverage, pe
Figure 5. COIA (Outcome Measures) Indicators Collected
< 5 Mortality
Maternal Mortality
Skilled attendant at birth
Antiretroviral
DPT Immunization
Antenatal Care
< 5 stunted
Antibiotic for Pneum.
Postnatal care
Contraception
Breastfeeding
0
2
4
6
8
10
12
14
16
18
Number of initiatives
17