A Real Test for the GFF: Improving Maternal and Child Health in Conflict Settings
July 25, 2015
A highlight of the Third International Conference on Financing for Development, held last week in Addis Ababa, Ethiopia, was the launch of a new Global Financing Facility (GFF) to end preventable maternal and child deaths by 2030. This partnership will bring together countries, UN agencies, multilateral groups, private sector investors, and civil society organizations in order to close the $33 billion annual funding gap for reproductive, maternal, newborn, child, and adolescent health (RMNCAH). A potential limitation of the GFF will be its ability to reach those living in conflict settings or fragile states, which will be key to achieving its goals of improving maternal and child survival.
In Addis, the United Nations and World Bank Group, along with the Governments of Canada, Norway, and the United States, announced $12 billion in support of five-year, country-led investment plans for maternal, child, and adolescent health in the Democratic Republic of the Congo (DRC), Ethiopia, Kenya, and Tanzania. In addition to these four “front-runner” countries, the partnership is projected to expand over the next five years to reach a total of 62 low- and lower-middle income countries, including 25 designated fragile situations. Along with the new Sustainable Development Goals (SDGs), the GFF is meant to encourage a more inclusive model of growth, but the question remains of how to reach women, children, and adolescents living in conflict settings or fragile states.
While maternal and child mortality have decreased by 50 percent globally since 1990, improving RMNCAH in fragile states represents an unfinished agenda for the Millennium Development Goals (MDGs). For example, the under-five mortality rate in war-torn Somalia is twice as high as the average for low-income countries; 146 of every 1,000 Somali children won’t live to see their fifth birthday. Maternal and child deaths and disability surge during and after conflict, due to the breakdown of often weak health systems and significant numbers of internally or externally displaced populations. While donors, UN agencies, and implementing organizations increasingly recognize the importance of RMNCAH in a humanitarian context – one example being the development of the Minimum Initial Service Package for Reproductive Health in Crisis Situations – the current availability of services falls far short of demonstrated need, reflecting operational and political hurdles, as well as a lack of resources.
In looking toward the post-2015 agenda and the SDGs, we must come to terms with some startling realities. This announcement of the GFF comes on the heels of new UNHCR statistics indicating that the world now has the largest population of displaced persons in recent history. An estimated 1.2-1.5 billion people, about one in five globally, live in countries affected by violent conflict. According to Save the Children, 56 percent of maternal and child deaths occur in fragile settings, and more than 80 percent of countries unlikely to achieve the MDGs for maternal and child survival have suffered a recent conflict or recurring natural disasters. Eight of the ten countries with the highest maternal mortality ratios (MMRs) are currently experiencing or emerging from conflict.
Still, donors invest less in fragile states, reflecting political calculations vis-à-vis heightened risks and costs. They are wary of some nations for good reason: security concerns and lack of institutional capacity make operating in places like the Central African Republic and Yemen particularly challenging. Yet other countries, such as Haiti and Liberia, reflect delicate but promising situations and warrant increased assistance.
In its efforts to close the funding gap, the GFF will focus heavily on domestic resource mobilization, including tax revenue, private sector investments, and country-led planning, all features that may prove difficult to execute in conflict areas and fragile states. The GFF concept note previews its potential limits in this regard: “for [lower-income countries] experiencing political instability and conflict, such as the Central African Republic, public financing and delivery systems may prove unfit for this purpose and GFF grants will use alternative financing routes to ensure access to basic RMNCAH services.” As the partnership expands, the GFF should prioritize articulating what these alternative funding sources will be.
Inclusion of the DRC in its first round of focus countries will also test the GFF’s ability to adapt its financing model to serve fragile states. The DRC has one of the highest MMRs in the world at 730 deaths per 100,000 live births, and is slowly recovering from what has been called the deadliest conflict since World War II. While the Second Congo War formally ended in 2003, many eastern areas remain under the control of armed rebel groups, and access to health care is severely limited in these regions. If the partnership succeeds in reducing maternal and child deaths in the DRC, this could prove a useful model for extending support to other countries experiencing violent conflict.
If we are to end preventable maternal and child deaths by 2030, initiatives such as the GFF should place a greater focus on improving health systems in fragile states, where the majority of these deaths occur. Closing the health gap between low- and high-income countries may very well entail a convergence of humanitarian and development assistance, as the line separating these two spheres continues to blur. It will not be easy, but failure to support expansion of RMNCAH services in conflict settings runs the risk of building a post-2015 global development agenda that is both exclusive and unattainable.