Towards 'Muskoka II': Reaching the Most Vulnerable and Expanding Accountability

Towards ‘Muskoka II’:
    Reaching the Most Vulnerable and Expanding Accountability
Muskoka I: A Wise Investment
Canada’s foresight in concentrating international attention and resources towards two of
the Millennium Development Goals that were the most seriously off track has proven to be a
wise investment. When women are able to live through childbirth, and children are enabled
to grow into productive adults, families can feel more secure, economies can grow, and
societies can break the cycle of poverty and begin to prosper.

Preliminary data from the Muskoka Initiative on Maternal Newborn and Child Health
(MNCH) is already showing remarkable results. Project data is showing a significant
increase in the number of live births attended by skilled health personnel, and the number
of women receiving fundamental antenatal and postnatal care - all major factors in
addressing the main causes of maternal and child mortality. Likewise, significant progress
in the number of infants and children receiving critical vaccinations, oral rehydration
therapy and antibiotics for suspected pneumonia is placing us firmly on the road to ending
preventable deaths within a generation.i

Globally, over 700,000 more children lived to their fifth birthday in 2011 than in 2010. In
over 125 countries, maternal death rates have declined sharply in the past five years. These
results not only reflect money well spent, but also the values of millions of Canadians who
support this effort.

Positioning ‘Muskoka II’ in the Post-2015 Framework
Canada’s initiative on MNCH and its leadership at the UN Commission on Information and
Accountability for Women’s and Children’s Health (COIA) has set a solid foundation for a
signature Canadian contribution to the post-2015 development framework. We propose
that this contribution recommit to the successful investments made in Muskoka I and place
a sharper focus on reaching the most vulnerable mothers, newborn and children within the
first 1000 days - so that they can not only survive, but thrive. In addition, Muskoka II should
include an expanded accountability agenda premised on Civil Registration and Vital
Statistics (CRVS) and data as the first step to seeing broader accountability to communities
themselves, across the full scope of the post 2015 development goals.

The global consultations around the new framework have clearly demonstrated that both
the current and proposed sustainable development goals are fundamentally interlinked.
Substantial progress on one goal requires sustained attention to others to maximize
opportunities and ensure that hard-won gains are maintained over the long-term. As such,
Canada’s efforts to catalyze progress on the health goals have laid the groundwork to see a
profound global impact across a range of challenges including poverty, gender equality,
child protection, greater security and economic prosperity. The challenge now is for Canada
to broaden and deepen the impact of the Muskoka Initiative on MNCH and champion an
expansion of the advancements and lessons learned from the COIA to bring a comparable
level of rigor and accountability to realizing the results of the broader post-2015 agenda.

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Three Pillars of Muskoka II: Maintain Momentum, Reach the Most Vulnerable, and
Expand Accountability

I. Maintain momentum so that women, newborns and children both survive and
thrive
Expanding on the promising results of Muskoka I, it is critical that Muskoka II maintain
momentum and renew our commitment to the integrated basket of high-impact
interventions delivered across the continuum of care. Deepening investments aimed at
strengthening local health systems – especially through training and education; reducing
the burden of infectious disease; and improving nutrition will maximize the impact of
current programming and position us to achieve even greater gains post-2015.

Building a strong foundation for healthy development, integrated with efforts to improve
maternal and child survival, is a prerequisite for individual well-being, economic
productivity, and harmonious societies around the world. It is critical to tackle the challenge
of developing sustainable ways to promote and nurture healthy child and brain
development in the first 1000 days at scale with lasting impact on human capital in low-
resource settings. There is an opportunity for Canada to show global leadership by
crystallizing & catalyzing this interest in integration of surviving and thriving, so all children
can reach their full potential.

II. Reach the most vulnerable women, newborns and children
While the progress on MDGs 4 and 5 has enabled and inspired improvements in millions of
lives around the world, the gap has widened, in many instances, between those who now
enjoy better opportunities and outcomes and those who were, or remain, excluded and
marginalized.

Aggregate measures of progress so far have tended to focus on the ’low-hanging fruit‘, or
the easiest to reach. Yet the lack of sufficient attention to who is benefiting and who is not,
risks undermining state’s human rights obligations as primary duty bearers, de-stabilizing
societies and undermining prosperity. As such, there is an emerging consensus within the
post-2015 consultations that the new framework must aim to directly tackle the
inequalities not just of wealth and income, but also of discrimination and social status that
persist within and between countries. Nearly a century of development experience has
shown that when you raise those at the bottom of the social economic ladder, you unlock
the key to seeing the benefits accrue to families, communities, and entire nations. UNICEF
research has also demonstrated that a focus on the hardest to reach is not only right in
principle and strategically sound; but is also good practice in that is amongst excluded
populations where we stand to make the greatest gains in terms of progress.ii

In line with an equity approach, it is therefore recommended that Canada focus a Muskoka
II on reaching the poorest and most vulnerable women and children as a primary objective.
By dismantling the barriers to access to health services and resources, we reduce the
burden of disease that affects the future of children, impoverishes entire families and passes
social injustice on through the generations.

III. Expand accountability
Canada’s leadership at the UN Commission on Information and Accountability for Women’s
and Children’s Health has brought an unprecedented level of clarity and focus to the task of
measuring the results of our joint efforts on MNCH. Drawing upon this experience, Canada

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is well positioned to deepen its efforts to and to expand its accountability agenda as the
cornerstone of its contribution to the wider post-2015 development framework. Timely,
reliable and accessible health information is a critical catalyst for accountability to
communities and within national health systems.

At the heart of this task is a commitment to Civil Registration and Vital Statistics (CRVS) and
data both as the legal basis for the realization of human rights, and the foundation for
rigorous and accurate accountability. Currently it is estimated that between 250 and 500
million women and children are invisible, or not officially counted or recognized. CRVS
begins with Universal Birth Registration as one of the most critical interventions to provide
children with legal protection against harmful practices such as child marriage, trafficking,
exploitation and abuse. By championing birth and death registration, Canada can play an
instrumental role in making the invisible, visible – a fundamental step towards reaching the
most vulnerable women and children in society and firmly integrating child protection into
the post 2015 framework. Beyond civil registration, a focus on vital statistics -
disaggregated by gender, location, age, ethnicity, disability and wealth - is the essential and
practical step forward in bringing an expanded accountability agenda to MNCH and the
broader post 2015 framework as a whole.

How We Can Get There? Recommendations:iii

I. Maintain momentum so that women, newborns and children both survive and
thrive
    1. Strengthen health systems by deepening investment in comprehensive, integrated
        evidence-based interventions and system infrastructure across the continuum of
        care.
    2. More fully integrate child development with maternal & child survival as a
        sustainable approach to improve life outcomes for those who live beyond the early
        childhood period yet face high risks for diminished life prospects.

II. Reach the most vulnerable women, newborns and children
     3. Strengthen investment in five proven areas across the continuum of care with
        the specific goal of reaching the most vulnerable mothers, newborns and children.
        These areas include:
             Prevention and treatment of neo-natal morbidity and mortality1
             Maternal and child nutrition
             Increased access to emergency obstetric care
             Prevention and treatment of childhood infectious diseases
             Investment in sexual and reproductive health interventions, with an
                emphasis on adolescent girls
     4. Step up efforts to target the hardest to reach in all areas of focus through the
        development of effective strategies to recruit, train, supply, deploy and support the
        full range of front line health workers along the continuum of care.

1Newborns currently account for 44% of all under five deaths. Consequently, it is strongly
recommended that Canada endorse the Every Newborn Action Plan, recognizing the implicit
importance of maternal and newborn health along the continuum of care.

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III. Expand Accountability
      5. Support the inclusion of a specific, high-level goal in the post-2015 framework to
          end preventable deaths and improve health outcomes of women, newborns and
          children.
      6. Broaden and strengthen MNCH Accountability Frameworks with a view to
         expanding accountability principles within the post 2015 framework.
              Champion a simplified, harmonized MNCH and nutrition accountability
                 framework as a central push toward MNCH targets in 2015 and beyond.
              Support community-based accountability mechanisms as a critical approach
                 to strengthening health service delivery and accountability to the poorest
                 and most marginalized women and children.
              Prioritize Universal Birth Registration as an essential child protection
                 intervention to address harmful practices such as child marriage.
              Invest in efforts to collect, process and disseminate more reliable data
                 through national surveys and CRVS.
              Support the scale-up of disaggregated vital statistics collection and enhance
                 local data-processing capacity.
              Consider weighted indicators to reflect progress on the hardest to reach.
                 Targets should only be considered ‘achieved’ if they are met for all relevant
                 income and social groups.
              Integrate indicators of child development into MNCH accountability
                 frameworks.

Multi-Stakeholder Partnerships to Achieve a More Ambitious Agenda
For Muskoka II to be successful in reaching the most vulnerable mothers, newborns and
children around the world, it is important to leverage gains made and draw upon a wider
spectrum of expertise and resources. Innovative multi-stakeholder partnerships are
critical - not only to leverage greater resources, but also to engage a fuller spectrum
partners in the task of improving health outcomes and seeing greater results. These should
include local governments, the private sector, civil society, the business community and
citizens themselves. At the same time, it is important that such partnerships adhere to
enhanced transparency and accountability mechanisms and indicators that are aligned with
the 2008 Accra Agenda for Action, 2011 Busan Partnership for Effective Development Co-
operation, the Global Reporting Initiative, the UN Guiding Principles on Business and
Human Rights and the related Children’s Rights and Business Principles.

Fundamentally, it is important that the Government of Canada ensure that multi-
stakeholder partnerships, particularly those involving the private sector complement
robust public sector interventions in MNCH and other development goals.

Canada’s Contribution: Financing
The Lancet Global Investment Framework for Women’s and Children’s Health has put
forward an accelerated health financing plan to reduce preventable deaths. This framework
proposes an additional $30billion per year by 2035, or a 2% increase in spending on MNCH
across domestic health budgets and international assistance for health. As a starting point
for discussion, a proportionate increase to the Canadian contribution would mean
sustaining the current funding envelope of $2.85billion and adding $375 million in new
funding for a total of $3.25 billion over five years. Additional funds for a Muskoka II should
be drawn from new funding and not allocated at the expense of other development
programs.

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Endnotes
iPreliminary data from projects have shown improved outcomes related to maternal, newborn and child health.
A few examples were selected below to highlight Canada’s impact.

Organization               Country                  Indicator                            % Change
Christian Children’s                                                                     Increase - 26% to 58%
                           Ethiopia                 Delivery at health facility
Fund of Canada                                                                           over two years
Ghana Rural
                                                    Skilled birth attendant present at   Increase - 50% to 82%
Integrated                 Ghana
                                                    birth                                over one year
Development
Healthy Children                                    Children underweight (