Estimates of aid for reproductive, maternal, newborn, and child health: findings from application of the Muskoka2 method, 2002-17.

BACKGROUND: Four methods have previously been used to track aid for reproductive, maternal, newborn, and child health (RMNCH). At a meeting of donors and stakeholders in May, 2018, a single, agreed method was requested to produce accurate, predictable, transparent, and up-to-date estimates that could be used for analyses from both donor and recipient perspectives. Muskoka2 was developed to meet these needs. We describe Muskoka2 and present estimates of levels and trends in aid for RMNCH in 2002-17, with a focus on the latest estimates for 2017. METHODS: Muskoka2 is an automated algorithm that generates disaggregated estimates of aid for reproductive health, maternal and newborn health, and child health at the global, donor, and recipient-country levels. We applied Muskoka2 to the Organisation for Economic Co-operation and Development's Creditor Reporting System (CRS) aid activities database to generate estimates of RMNCH disbursements in 2002-17. The percentage of disbursements that benefit RMNCH was determined using CRS purpose codes for all donors except Gavi, the Vaccine Alliance; the UN Population Fund; and UNICEF; for which fixed percentages of aid were considered to benefit RMNCH. We analysed funding by donor for the 20 largest donors, by recipient-country income group, and by recipient for the 16 countries with the greatest RMNCH need, defined as the countries with the worst levels in 2015 on each of seven health indicators. FINDINGS: After 3 years of stagnation, reported aid for RMNCH reached $15·9 billion in 2017, the highest amount ever reported. Among donors reporting in both 2016 and 2017, aid increased by 10% ($1·4 billion) to $15·4 billion between 2016 and 2017. Child health received almost half of RMNCH disbursements in 2017 (46%, $7·4 billion), followed by reproductive health (34%, $5·4 billion), and maternal and newborn health (19%, $3·1 billion). The USA ($5·8 billion) and the UK ($1·6 billion) were the largest bilateral donors, disbursing 46% of all RMNCH funding in 2017 (including shares of their core contributions to multilaterals). The Global Fund and Gavi were the largest multilateral donors, disbursing $1·7 billion and $1·5 billion, respectively, for RMNCH from their core budgets. The proportion of aid for RMNCH received by low-income countries increased from 31% in 2002 to 52% in 2017. Nigeria received 7% ($1·1 billion) of all aid for RMNCH in 2017, followed by Ethiopia (6%, $876 million), Kenya (5%, $754 million), and Tanzania (5%, $751 million). INTERPRETATION: Muskoka2 retains the speed, transparency, and donor buy-in of the G8's previous Muskoka approach and incorporates eight innovations to improve precision. Although aid for RMNCH increased in 2017, low-income and middle-income countries still experience substantial funding gaps and threats to future funding. Maternal and newborn health receives considerably less funding than reproductive health or child health, which is a persistent issue requiring urgent attention. FUNDING: Bill & Melinda Gates Foundation; Partnership for Maternal, Newborn & Child Health.

Increasing Contraceptive Access for Hard-to-Reach Populations With Vouchers and Social Franchising in Uganda.

From 2001 to 2011, modern contraceptive prevalence in Uganda increased from 18% to 26%. However, modern method use, in particular use of long-acting reversible contraceptives (LARCs) and permanent methods (PMs), remained low. In the 2011 Uganda Demographic and Health Survey, only 1 of 5 married women used a LARC or PM even though 34% indicated an unmet need for contraception. Between 2011 and 2014, a social franchise and family planning voucher program, supporting 400 private facilities to provide family planning counseling and broaden contraceptive choice by adding LARCs and PMs to the service mix, offered a voucher to enable poor women to access family planning services at franchised facilities. This study analyzes service trends and voucher client demographics and estimates the contribution of the program to increasing contraceptive prevalence in Uganda, using the Impact 2 model developed by Marie Stopes International. Between March 2011 and December 2014, 330,826 women received a family planning service using the voucher, of which 70% of voucher clients chose an implant and 25% chose an intrauterine device. The median age of voucher users was 28 years; 79% had no education or only a primary education; and 48% reported they were unemployed or a housewife. We estimated that by 2014, 280,000 of the approximately 8,600,000 women of reproductive age in Uganda were using a contraceptive method provided by the program and that 120,000 of the clients were "additional users" of contraception, contributing 1.4 percentage points to the national modern contraceptive prevalence rate. The combination of family planning vouchers and a franchise-based quality improvement initiative can leverage existing private health infrastructure to substantially expand family planning access and choice for disadvantaged populations and potentially improve contraceptive prevalence when scaled nationally.

A decade of improvements in equity of access to reproductive and maternal health services in Cambodia, 2000-2010.

INTRODUCTION: Despite encouraging reductions in global maternal mortality rates, Millennium Development Goal (MDG) 5 on reducing maternal mortality and achieving universal access to reproductive health remains the most off-track of all MDGs. Furthermore a preoccupation with aggregate coverage statistics masks extensive disparities in health improvements between societal groups. Recent national health indicators for Cambodia highlight impressive improvements, for example, in maternal, infant and child mortality, whilst substantial government commitments have been made since 2000 to address health inequities. It is therefore timely to explore the extent of equity in access to key reproductive and maternal health services in Cambodia and how this has changed over time. METHODS: Analysis was conducted on three rounds of Demographic and Health Survey data from 2000, 2005 and 2010. Outcome variables comprised utilisation of six reproductive and maternal health services--antenatal care, skilled birth attendance, facility-based delivery, postnatal care, met need for family planning and abortion by skilled provider. Four equity measures were calculated--equity gaps, equity ratios, concentration curves and concentration indices. Household assets were used to create the social-stratification variable, using principal components analysis. RESULTS: Coverage levels of all six services improved over the decade. Coverage improvements were greatest amongst wealthier quintiles of the population, although poorer quintiles also increased use of services. Critically, inequity in service use of all services dramatically reduced over time, except for postnatal care where inequity increased slightly. However, in 2010 inequity in service use remained favouring wealthier quintiles, greatest in use of skilled birth attendance and facility-based delivery, though the magnitude of inequity was substantially reduced compared to 2000. Met need for family planning was almost perfectly equitable in 2010. CONCLUSIONS: Cambodia has made impressive improvements in overall coverage of reproductive and maternal health services over the last decade, and also in the distribution of their use across wealth quintiles. A range of pro-poor health financing and supply-side policies as well as non-health factors may have contributed to these achievements. Further research will explore specific schemes qualitatively and quantitatively to assess their impact on equity and service use.