Show Us the Money

Wondering what to give your mother for Mother's Day? Flowers? A dinner out? Well, the leaders of the G8, who are meeting in Halifax before Mother's Day could give all the world's mothers a great gift - a genuine commitment to reducing maternal mortality.

The world's mothers need access to information and adequately resourced health services to meet their needs during and after pregnancy and during childbirth. They also need to know that when the system fails, someone will be held accountable for the failure.

By making maternal and child health a priority for the G8 discussions in June, Canada has given pregnant women a reason to hope that more of them will survive to celebrate the birth of their child and their own good health. What is even more reassuring is that the G8 has also announced that accountability will be a key theme of their discussions.

But platitudes about accountability will not do. Mechanisms for health system accountability--that is, identifying and rectifying health system failings-- are not created out of thin air. They require time and resources. Steps such as setting up systems to investigate maternal deaths so that health system gaps can be identified and fixed and giving women access to a hotline to seek emergency care will go a long way to ensure that women do not die needlessly. And guaranteeing that women can speak fearlessly about the problems they faced while trying to seek care, and having their grievances addressed will improve poor women's trust in public health systems.

While information about some of these mechanisms is easily available, some successful initiatives are not so well known. Often one is met with the "show me a model" response when speaking to government health officials about accountability. The G8 should not limit its discussion to its unmet promise to double development assistance by 2010. It should also make a more significant and critical contribution at this stage by earmarking donor assistance for documenting and disseminating good practices that create health system accountability.

A number of initiatives across the globe have resulted in better maternal health outcomes. In India, for example, the southern Indian state of Tamil Nadu has taken the lead since 1996 in investigating maternal deaths so that health system shortcomings that failed to prevent many of them could be fixed. This has placed Tamil Nadu far ahead of other Indian states in reducing the maternal death rate. Similarly, health experts say that western Rajasthan state's hotline for pregnant women has helped improve their access to care during emergencies. The G8 can set up systems to help countries share and replicate successes like these.

And in areas in which no one has yet come up with good solutions to some of the problems, the G8 should support research and development to develop accountability mechanisms, as recommended by its Health Experts Group in 2008. By documenting, disseminating, and urging governments to put in place these health care accountability systems, the G8 will ensure that the money being given in donor assistance is actually being spent, and spent well. Not just that - the G8 will ensure that money generated domestically by governments for health care is also being spent where it is needed.

The latest report by the highest auditing authority in India, the Comptroller and Auditor General of India (CAG), covering health care spending from 2005 through 2008, is replete with examples of how millions of dollars were lying unspent in government accounts. Even where money was spent it was unclear where and how - between 2005 and 2008 USD 916 million was spent on health but not accounted for.

To make matters worse, governments spent large amounts hurriedly in March, just before close of fiscal year, apparently to show it was being used, and leaving little confidence that it went where it was needed. Unutilized money or money spent this way points to the grave deficiencies in oversight in planning for and implementing health care programs. What is desperately needed to stop more mothers from dying is to make health systems accountable. That cannot be equated with sacking frontline health workers, but instead it requires the political will and resources to ensure that health system flaws are fixed and good practices implemented. A generous check from the G8 to improve accountability in maternal health would make a very nice Mother's Day gift!

Aruna Kashyap is a researcher in the Women's Rights Division of Human Rights Watch, based in Mumbai.