Administrator U.S. Agency for International Development 1300 Pennsylvania Avenue, NW Washington, DC 20523 USA

Better information for better results Better tracking of resources for women’s and children’s health Better oversight of results and resources: nationally and globally

Dr Rajiv Shah Administrator U.S. Agency for International Development 1300 Pennsylvania Avenue, NW Washington, DC 20523 USA

May 31, 2012

Dear Rajiv,

We are writing to you as members of the independent Expert Review Group (iERG), a 7-person body created by the UN Secretary-General's Commission on Information and Accountability for Women's and Children's Health. Our task is to serve as the principal global review group on accountability for the Global Strategy on Women's and Children's Health, "Every Woman, Every Child". We report to the UN Secretary-General, through WHO's Director-General. We are tasked with producing an annual report on accountability for women's and children's health, released in September at the UN General Assembly,

We are aware that a meeting is soon to take place in Washington, DC (June 14-15) - "Child Survival Call to Action: Ending Preventable Child Deaths." This meeting, we understand, is being convened by the governments of the US, India, and Ethiopia, in partnership with UNICEF. Although several entities are involved, much of the visible leadership seems to be coming from the US, and specifically USAID. For example, it was mostly your colleague, Dr Ariel Pablos-Mendez, who ably and powerfully represented the purpose and goals of the Call to Action at the recent World Health Assembly in Geneva. We also understand that USAID has also been convening the preparatory meetings for the event. While it is commendable that there is to be increased global attention to child survival, we are conscious of concerns about this forthcoming meeting. We wish to summarise and convey these concerns to you, as colleagues working together with you for women's and children's health, but also as part of the emerging global oversight mechanism for women's and children's health put in place by the UN Secretary-General. These concerns are not ours alone. We have heard them expressed by many parties working in women's and children's health.

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Independent Expert Review Group (iERG) of the Commission on Information and Accountability for Women's and Children's Health Secretariat hosted by the World Health Organization Room 3154, 20 avenue Appia, 1211 Geneva 27, Switzerland Email: [email protected] Website: www.who.int/woman_child_accountability/ierg/¨

Better information for better results Better tracking of resources for women’s and children’s health Better oversight of results and resources: nationally and globally

1. There is considerable disquiet about the process leading to this meeting. The MDGs set targets that were agreed multilaterally through UN processes by all countries of the world. The success in mobilising countries and donors, among others, to commit politically to these goals came from the democratic, participatory, and multilateral process that produced them. There has been no such UN member-state driven process (that we are aware of) to set the new target of 2 million under- 5 deaths by 2035. Several of us are aware, however, of considerable concerns from country representatives about another goal being imposed in this way, outside of the usual multilateral mechanisms.

2. The meeting is branded as a "Child Survival Call to Action". It has taken a decade of hard work and successful collaboration to create the notion of the continuum of care - programmatically addressing the need to tackle MDGs 1c, 4, 5, and part of 6 (PMTCT) through a comprehensive and integrated approach to reproductive, maternal, newborn, and child health. The meeting in June emphasises child survival in a way that may take us backwards, not forwards, from this concept. We have heard this view expressed strongly by many who work in other areas of the continuum of care. Branding a meeting as exclusively focused on child survival risks damaging the programmatic progress we have all made during the past decade.

3. We have learned that a new scorecard is being designed to monitor progress towards the new 2035 goal. However, again after a decade of work, there is already a widely agreed scorecard - that produced by the Countdown to 2015 group. We are puzzled as to why another competing scorecard is being devised. This parallel initiative will produce duplication and potentially confuse and dilute the efforts so far made to create a successful accountability mechanism across the continuum of care. We would welcome your clarification as to the need for yet another competing scorecard.

4. We are concerned about feasibility. The average annual decline in child mortality for high- burden countries has been around 2% . The MDG goal required a decline of 4.3%, a tough but still feasible target. Attaining the proposed 2035 goal would require long-term annual rates of under-5 mortality decline that have been achieved by, at most, only a handful of countries over much more limited periods. While we strongly endorse the idea of challenging aspirational goals, we are anxious that an unfeasible goal will simply be another way to show that Africa has "failed". We do not see this possible result as helpful to making global progress in women's and children's health.

5. We are also anxious that a 2035 target - 23 years away - is simply too distant to be politically realistic. The temptation for parties to the goal in June to postpone action, given the limited immediate political pressure to act and the lack of multilateral mechanisms for accountability, is potentially great.

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Better information for better results Better tracking of resources for women’s and children’s health Better oversight of results and resources: nationally and globally

We would like to underline again that the concerns we are expressing are not ours alone. We have heard them repeated by colleagues in countries, civil society, other UN agencies, and academia. The members of the iERG are unswerving in our commitment to support the Secretary-General's ambitious and entirely achievable Global Strategy, "Every Woman, Every Child". But we are concerned that the Child Survival Call to Action may inadvertently trigger a set of events that divert global attention from the broader agenda of women's and children's health that many of us have fought so hard for, as you have, this past decade.

We have two recommendations. First, that the June meeting be framed very differently. We believe it is imperative that the meeting - in its title and content on both days - be organised around the continuum of care. We believe that most members of the child survival community would endorse such a shift in emphasis. Second, we suggest that the meeting is constructed as a proposal to the global community for the post-2015 period. We believe, based on our consultations with many parties, that the meeting you are organising would then be seen, first, as a valuable opportunity to reflect on the lessons of past success and, second, as a means to begin the translation of those lessons into new goals (perhaps as part of the Sustainable Development Goal process now in its early stages of discussion and planning). You would also be able to use the meeting to launch an intensive period of discussion within, and led by, countries. This way, we keep the 2015 MDG target firmly in place, but use the Washington event as a platform for looking forward, inviting others to join what needs to be a participatory, multilaterally led process. The iERG would very much support such a framing for the meeting on June 14-15, and we would be keen to be part - as an accountability mechanism - of the follow up.

We look forward very much to hearing from you soon.

Yours faithfully,

The Members of the iERG

Carmen Barroso Zulfiqar Bhutta Richard Horton (Co-Chair) Dean Jamison Joy Phumaphi (Co-Chair) Marleen Temmerman Miriam Were

cc: Mr. Ban Ki-moon, United Nations Secretary-General Dr. Margaret Chan, WHO Director General Mr. Anthony Lake, UNICEF Executive Director Shri. Ghulam Nabi Azad, Minister of Health and Family Welfare, India Dr. Tedros Adhanom, Minister of Health, Ethiopia 3/3