“What gets measured is what matters.” This saying raises the question: who decides what matters? Establishing global targets and strategies can help countries galvanize political will, global and domestic funding, and focus attention on improving maternal health. At the same time, the global measurement frameworks that track progress across countries are funded and organized by a relatively small number of organizations in high-income countries. Critics have argued that determining what gets measured from the top down by a “global health metrics enterprise” does not adequately reflect country-level inputs and may actually hamper national measurement capacity, relevance, and utility. Proponents of global measurement frameworks counter that measurement capacity and data quality can vary greatly between countries, and that country comparisons furnish important incentives for countries to set and achieve national targets. This ongoing debate prompts a pause to consider whether the key question is, “What should be measured?” or rather, “Who should set the measurement agenda?”
At the advent of the Sustainable Development Goals (SDGs) in 2015, the Kirkland Group, a group of global experts in MNH measurement convened by the Bill and Melinda Gates Foundation, published a call to action for the global maternal newborn health (MNH) measurement community. Drawing on successes in monitoring the coverage of effective interventions to prevent and treat infectious diseases, the group called for measurement efforts to focus on the coverage of MNH interventions proven effective to reduce mortality, and proposed five principles on which the global MNH measurement agenda should be founded: Focus, Relevance, Innovation, Equity, and Leadership.
Focus would be reflected in a small core set of standard global indicators of effective coverage of key interventions for maternal, newborn and child health (MNCH) that should be cost-effective, feasible, and informative. Measures should be drawn from a menu of standard process and quality indicators vetted by global experts and UN agencies, and could be tailored for context. Relevance would be assured through the leadership of national governments to select useful measures and to allocate resources toward improving local measurement capacity to ensure they be used. Innovation would be key to allow data on coverage of interventions to be collected through more effective and efficient means than direct observation or population-based surveys. Equity would be achieved by ensuring disaggregation of all measures to capture subpopulation disparities, especially differences in coverage and quality of services for those typically marginalized. Finally, global leadership would be necessary to ensure that MNH and its continued improvement through monitoring and use of measurement data remain high on the global health agenda.
While the original Kirkland Group principles prioritized a framework for monitoring effective coverage of MNH interventions within health facilities, the SDG agenda is far broader, and ending all preventable maternal deaths in kind requires a wider lens. The determinants and distribution of risk and the causes of maternal death vary in countries around the world based on factors that have their roots upstream from the delivery of lifesaving interventions. For example, without measures of health system strengthening and facility readiness, the rate of institutional deliveries may not serve as a strong core measure of the quality and safety of birth within and across all countries; without quality assurance, setting targets for this indicator may drive birthing people into deficient facilities, worsening outcomes. Moreover, one fifth of countries do not have effective vital statistics systems to register and certify the causes of maternal deaths, information essential for planning effective maternal and newborn health care. Measuring what matters is decidedly context-specific.
The scope of the original Kirkland principles must be broadened beyond coverage of key clinical interventions. Most importantly, the locus of power must be shifted from global to local. At the 5-year milestone of the SDGs in 2020, the original framers of the Kirkland principles reconvened a group of measurement experts, this time in Nairobi, Kenya, to re-assess the five original principles and to issue a new call to action. The result was the addition of a sixth organizing principle, that of country ownership, through which the original five principles should be funneled, making clear that it is country perspectives about local priorities and pain points that must be addressed to improve MNH.
The Improving Maternal Health Measurement (IMHM) Project, directed by Dr. Rima Jolivet, with Dr. Jewel Gausman, and Dr. Ana Langer at the Women & Health Initiative, has built the principle of country ownership into its work to strengthen MNH measurement. The IMHM project and its partners, the White Ribbon Alliance and the FCI Program of MSH, have facilitated seven national dialogues in Bangladesh, Cote d’Ivoire, India, Kenya, Mexico, Pakistan, and Nigeria in partnership with local Ministries of Health, civil society advocates, and other development partners to delineate country-specific priorities for MNH measurement. These dialogues, meant to foster country leadership and ownership by including diverse perspectives from multiple sectors, were first suggested by country-level advocates themselves.
Kenya was the trailblazer in the dialogue series, and helped highlight the importance of determining measurement targets in the context of country-specific strategic priorities. In this first national dialogue, participants were presented with the full list of indicators from the monitoring framework for the “Strategies toward Ending Maternal Mortality (EPMM)” and asked to choose the most important indicators independent from the 11 Key Themes they were designed to monitor. What resulted was less consensus around the most important measures because the process did not ask participants to deliberate and reach agreement on their national MNH priorities and current pain points first. Based on participant feedback and lessons learned in Kenya, participants in the remaining national dialogues began by discussing and prioritizing the top three areas of the maternal health system where improvement is needed and went on to identify specific measurement goals based on those priorities. What emerged in subsequent national dialogues was a more coherent narrative and greater consensus about what counted most and should be counted in each country to confront the biggest challenges standing in the way of ending preventable maternal mortality.
As the global epidemiology of maternal health and survival shifts in countries around the world, the capacity to choose measures and build national monitoring frameworks is as important as ever. Just as the word “milestone” represents a marker set up beside a road to mark the distance in miles to a particular place, the MNH measurement agenda to reach the SDGs must be set by those who walk their varied paths to reach it, and as the IMHM project’s dialogues demonstrate, country leaders are ready and equipped for the journey.