The political process in global health and nutrition governance: the G8's 2010 Muskoka Initiative on Maternal, Child, and Newborn Health.

Ann. N.Y. Acad. Sci. ISSN 0077-8923

A N N A L S O F T H E N E W Y O R K A C A D E M Y O F SC I E N C E S Issue: Paths of Convergence for Agriculture, Health, and Wealth

The political process in global health and nutrition governance: the G8’s 2010 Muskoka Initiative on Maternal, Child, and Newborn Health John Kirton, Julia Kulik, and Caroline Bracht G8 Research Group, University of Toronto, Toronto, Ontario, Canada Address for correspondence: John Kirton, Munk School of Global Affairs, 1 Devonshire Place, Room 209N, Toronto ON M5S 3K7 Canada. [email protected]

Why do informal, plurilateral summit institutions such as the Group of Eight (G8) major market democracies succeed in advancing costly public health priorities such as maternal, newborn, and child health (MNCH), even when the formal, multilateral United Nations (UN) system fails to meet such goals, when G8 governments afflicted by recession, deficit, and debt seek to cut expenditures, and when the private sector is largely uninvolved, despite the growing popularity of public–private partnerships to meet global health and related nutrition, food, and agriculture needs? Guided by the concert-equality model of G8 governance, this case study of the G8’s 2010 Muskoka Initiative on MNCH traces the process through which that initiative was planned within Canada, internationally prepared through negotiations with Canada’s G8 partners, produced at Muskoka by the leaders in June, multiplied in its results by the UN summit in September, and reinforced by the new accountability mechanism put in place. It finds that the Muskoka summit succeeded in mobilizing major money and momentum for MNCH. This was due to the initiative and influence of children-focused nongovernmental organizations (NGOs), working with committed individuals and agencies within the host Canadian government, as well as supportive public opinion and the help of those in the UN responsible for realizing its Millennium Development Goals. Also relevant were the democratic like-mindedness of G8 leaders and their African partners, the deference of G8 members to the host’s priority, and the need of the G8 to demonstrate its relevance through a division of labor between it and the new Group of Twenty summit. This study shows that G8 summits can succeed in advancing key global health issues without a global shock on the same subject to galvanize agreement and action. It suggests that, when committed, focused NGOs and government officials will lead and the private sector will follow, but that there will be a lag in the implementation needed to obtain the intended results. The need to improve the accompanying accountability mechanisms to improve implementation, thus, remains. Keywords: maternal, newborn, and child health; G8 summit; global health governance; global nutrition governance

Introduction Why do informal, plurilateral summit institutions such as the Group of Eight (G8) major market democracies succeed in advancing costly public health priorities such as maternal, newborn, and child health (MNCH), even when the formal, multilateral United Nations (UN) system fails to meet such goals, when G8 governments afflicted by recession, deficit, and debt seek to cut expenditures, and when the private sector is largely uninvolved,

despite the growing popularity of public–private partnerships to meet global health and related nutrition, food, and agriculture needs? One recent case where the G8 did so under these difficult conditions was its Muskoka Initiative on MNCH. Through it, the G8 in June 2010 mobilized $7.3 billion to meet the badly lagging Millennium Development Goals (MDGs) 4 and 5, spurred the UN to multiply this to $40 billion at its summit that September, and added a dedicated accountability commission to help ensure that the promised doi: 10.1111/nyas.12494

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C 2014 New York Academy of Sciences. Ann. N.Y. Acad. Sci. 1331 (2014) 186–200

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money was delivered and produced the intended results. An analytically disciplined, evidence-based answer to this question through this critical case study will contribute to an improved understanding of the dynamics of effective global governance and of how the global community can better meet its still-unfulfilled MDGs as their due date rapidly approaches in 2015. Thus far, 3 decades of scholarship on G8 governance and on the related, more recent Group of Twenty (G20) has produced several competing causal models of why such institutions succeed or fail.1–4 The most well-developed and welltested model of G8 governance, the concert-equality model, assesses summit performance across six dimensions: domestic political management; private and public deliberation; principled and normative direction setting; collective decision making; delivery of these decisions through implementing action by the members; and the development of global governance both inside and outside the G8. It hypothesizes and empirically claims that strong G8 performance arises from six key causes: a shock on the same subject that activates the vulnerability of all members; the failure of the UN-centered multilateral organizations to respond adequately; the global predominance and international equality of G8 members in the capabilities needed to counter the shock; their democratic like-mindedness; their domestic political cohesion; and the ability of their leaders to produce timely, well-tailored responses through their compact summit club.5,6 Yet here the strong performance of the G8’s Muskoka Initiative presents this model with a major puzzle. There was no sudden, severe global shock of a spike in maternal and child deaths in the leadup to the Muskoka summit, but only financial and food crises that should have led the summit to focus on these issues, as it had the previous year. Moreover, most G8 governments were still reeling from the 2008–2009 global financial crisis and subsequent Euro-crisis that had erupted in Greece in early 2010, and were thus moving to control expenditures, including in official development assistance (ODA), to ensure market confidence in the face of their ballooning government deficits and debts.7 The MNCH cause could have been safely left to the UN, which had its own MDG review summit in September and for which 5 years remained before MDGs 4 and 5 were due. It could also have been

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left to the more rapidly growing emerging and developing countries, assembled in the new summits of the G20 and the BRICS (Brazil, Russia, India, China, and South Africa), because their own citizens were most affected and their governments had the new resources to meet the need. Neither the host of the Muskoka summit, Canadian Prime Minister Stephen Harper, nor any of his fellow G8 leaders had previously been personally or politically committed to the MNCH cause. And the Muskoka summit was shortened and overshadowed by the much larger and more prominent G20 summit taking place immediately after in nearby Toronto. This article argues that the strong success of the Muskoka summit in mobilizing money and momentum for MNCH was due importantly to the initiative and influence of children-focused nongovernmental organizations (NGOs) working with committed individuals and agencies within the host Canadian government, supportive public opinion, and the help of those responsible at the UN for realizing its existing MDGs. Also relevant were the democratic like-mindedness of G8 leaders and their African partners, the deference of G8 members to the host’s priority, and the need of the G8 to demonstrate its relevance through a division of labor between a G8 still advancing development through ODA and a G20 now starting to do so in other ways. Together, this study suggests that, where committed, focused NGOs and government officials will lead and the private sector will follow to make important advances on key global health priorities, even if there is a lag in the implementation needed to obtain the intended results and, thus, a need for improvements in the accompanying accountability mechanisms. To arrive at this answer, this article traces, in turn, in as much detail as is empirically possible at this stage, the process by which the Muskoka summit and its MNCH were planned in Canada, internationally prepared through negotiations with Canada’s G8 partners, produced at Muskoka by the leaders, multiplied in their results by the UN summit in September, and reinforced by the new accountability mechanism put in place. In doing so, it mobilizes the often-used and well-developed method in the social sciences of conducting a single critical case study, using detailed process tracing and historical explanations to connect observed and surprising outcomes with their underlying causes.8 It


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uses the relevant standards for scientific inference in conducting such qualitative research.9 It thus seeks to avoid several of the analytical and empirical shortcomings arising in similar case studies in health policy analysis in low- and middle-income countries.10 For materials providing evidence, this study relies on the relevant scholarly literature, especially in peer-refereed articles, collections, and books; pieces written throughout the process and subsequently by the leaders and other individuals closest to the center of the decision-making process; biographies of them; and extensive primary sources, from legislative proceedings, NGO documents, public opinion polls, and newspaper and television stories. Importantly, it employs the results of 65 public briefings, conference presentations and papers, panel discussions, media scrums, conversations, and factual private interviews with key participants in the process. These include individuals in G8 governments, from the level of leaders, through relevant ministers, to mid-level officials and those in the key civil society organizations involved. To a lesser extent, it includes representatives of the private sector. These materials were assembled from a majority of the G8 member countries, from 2008 to 2014. Such evidence is triangulated among several sources, and regarded as reliable if it is, at a minimum, recounted in some detail by one source in a position to know, supported by other sources, and not contradicted by others (in which case a high standard of confirmation by others is required). Such accounts must also be consistent with the public record. This method and set of materials are adequate for this first-generation study of the Muskoka Initiative, recognizing that more will be known when government documents are made available and the leaders’ autobiographies are produced. The global challenge and context On January 1, 2010, Canada assumed the chair of the G8 for its 36th annual summit, held in Huntsville, Ontario, on June 25–26, 2010. Globally at that time, over half a million women died annually in pregnancy and childbirth.11 Nearly 9 million children under age 5 died.12 These deaths occurred despite the presence of proven, low-cost, simple, straightforward interventions in health and nutrition.11 Although the UN had adopted child and maternal health as two of its eight MDGs launched in 2000 and due for delivery in 2015, as 2010 opened, 188

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the maternal mortality goal was the furthest from realization.13 None of the trillions of dollars raised to combat the global financial and economic crisis by the new G20 summit, beginning at Washington in November 2008 and continuing at London in April 2009 and Pittsburgh in September 2009, were directly devoted to these goals, despite the further damage this global shock did to the world’s poorest and most vulnerable. It was thus left to the older, smaller G8, which had long led on health and development issues, to take up the cause, should its host and members so choose. Within 3 weeks of Canada assuming the G8 chair on January 1, 2010, child and maternal health became its summit’s priority. Six months later, the Muskoka Initiative on Maternal, Newborn, and Child Health became the signature achievement of the summit.14,15 The compact club of G8 members at Muskoka and their partners mobilized an additional $7.3 billion for the cause, catalyzed a total of $40 billion in such pledges at the UN’s MDG review summit 10 weeks later in New York, inspired the creation of a dedicated accountability commission to help ensure its effectiveness, and advanced progress toward the child and maternal MDGs.16 Plans and preparations This attention to MNCH was entirely absent when the Canadian government’s planning for the 2010 G8 summit began in November 2007. At that time, officials began holding full-day interdepartmental meetings to identify the priority themes. The first topics proposed were democratization, Africa, compliance, energy, the Arctic, and institutional architecture including a potential “Group of 13” consisting of the G8 plus its outreach partners. Neither health nor development was on the list. In the summer of 2008, Harper17 publicly announced that the summit’s three themes would be economic growth and trade; climate change; and freedom, democracy, the rule of law, and human rights. Health and development, again, did not appear. Health first appeared only 1 year later when, in the lead-up to the 2009 G8 L’Aquila summit held on July 8–10, 2009, Harper extended the thematic list. Added as a fourth pillar was development with an emphasis on health, including maternal and children’s health. Harper wrote:


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The G8 has long played a leadership role in international development. It includes some of the world’s largest donors, which account for approximately two-thirds of ODA. The G8 has also provided about 80% of all funds for the Global Fund to Fight AIDS, Tuberculosis, and Malaria and 50% of all funds to the Global Polio Eradication Initiative (including 98% of all national contributions). In the short term and in the context of the global economic crisis, the G8 can help free up resources for development to restore the economic growth that is essential for sustained poverty reduction. The G8 can also continue to maintain international attention on the social dimensions of development—health, education, and the critical areas of maternal and childhood well-being.18 However, it was still unclear how prominent and ambitious the maternal and child health issue would be. Starting in August 2009, interdepartmental task forces led by the G8 summit planners in the Department of Foreign Affairs and International Trade developed proposals for possible G8 initiatives for the consideration of the prime minister and his staff. They proposed initiatives on food security, on research and innovation for development, and on security vulnerabilities in fragile and failing states. While these secured interdepartmental consensus, as the autumn turned to winter, it remained unclear whether the agenda would meet with the approval of the Prime Minister’s Office (PMO) and the prime minister himself. Health was present but not prominent on the list. To determine how health in general and MNCH in particular became the central priority when Canada formally assumed the chair of the G8 on January 1, 2010, it is necessary to trace the activities and impact of key actors at the governmental and societal level within Canada, and of the most relevant institutions at the international level outside.19 Civil society initiation and mobilization The prime minister’s public choice in June 2009 of MNCH as the one specified “critical area” for this new summit priority and its eventual success flowed, in the first instance, from the work of a group of Canada-based children-focused NGOs, led by World Vision, Plan Canada, and Save the Children, with UNICEF Canada, Care Canada, RE-


SULTS Canada, and Action Canada for Population and Development joining later to form the Canadian Coalition for Maternal, Newborn, and Child Health (CCMNCH).20 Backed by almost 2 million members, the coalition’s mobilization had begun in the spring of 2006 when World Vision identified a lack of coordination on advocacy and looked to see what issue needed global leadership. In its 60-year history, World Vision, a front-line service delivery organization in the field, had never focused on advocacy, let alone on one global advocacy campaign. The federal structure of World Vision created local-office autonomy and coordination difficulties at the global level. A looming awareness of a desire by some to build an advocacy pillar within the organization caused individuals at World Vision to process trace their activities and impact and to hire a director of external relations. World Vision’s links to grassroots communities were clear, but the delivery of that information to governments and international bodies was less so. The director of external relations was tasked to identify key international meetings and opportunities for influence. With its area of expertise being children, and acknowledging that, in order to have healthy children, mothers must be healthy, World Vision decided to conduct a global advocacy campaign and to focus its campaign on MDGs 4 and 5, the most stalled goals. In parallel, in May 2008, during the global food crisis, Save the Children had started the “Every One” campaign, holding discussions with World Vision and UNICEF. Other international NGOs began considering options for their next 5-year campaign. In the summer of 2008, Save the Children met with Robert Fowler and Gordon Smith, former Canadian G8 personal representatives of the prime ministers (or “sherpas”) to discuss Canada’s presidency of the G8 and how to influence its agenda. In the fall of 2008 and into 2009, Save the Children started assembling a 2010–2015 child-survival campaign, called “Every Beat Matters,” intending to take advantage of the lagging MDGs 4 and 5. It also worked nationally with Plan Canada and CARE on HIV programs at the technical level. These groups were also members of a broader coalition of major Canadian NGOs and labor, student, and faith-based groups that launched “At the Table” as an extension of the Make Poverty History campaign.


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Save the Children produced a set plan on MNCH in November 2008. In March 2009, its concept was presented to the PMO. In early spring 2009, Smith and Fowler told Save the Children that the NGOs would have to work together to be effective. Save the Children brought UNICEF’s Canadian committee into the campaign, started developing briefs, hired a staff member to work on the campaign, and began talking to the health officials at the Canadian International Development Agency (CIDA). The coalition secured broader public support from the results of an Ipsos-Reid public-opinion poll in November 2009 showing that 87% of Canadians agreed that Canada “should keep its promises to reduce childhood deaths despite the economic downturn.”21 In December 2009, representatives of the coalition met with senior political CIDA and PMO officials. They were also in contact with the Canadian sherpa team. On January 11, 2010, they were asked to meet with Canadian sherpa Len Edwards to speak with him and his health advisor, Tracy Fyfe, to pitch its campaign. Coalition representatives felt that the meeting had gone well and that Edwards was receptive to their ideas. They were able to demonstrate to the satisfaction of Canada’s summit planners that a Canadian initiative on MNCH would secure strong support from summit partners, led by the United States and the United Kingdom. Canadian government support A second source of support for the Muskoka Initiative came from within the Canadian government, based on CIDA’s earlier investments in multilateral MNCH initiatives, starting with the Accelerated Child Survival and Development project.20 In November 2007, Canada had become a leading funder of the Catalytic Initiative to Save a Million Lives, which the coalition now sought to scale up significantly through the G8.22 More broadly, the development strategy that CIDA had been working on since the summer of 2009 identified health as a priority, including MNCH.23 UN support and failure A third source of support for the coalition’s initiative came from the full international community through the UN. At the summit level in 2000, it provided the agreed goals and 2015 deadline, as well as ongoing advocates led by UNICEF.24 Leaders of all 192 members of the UN met in September 2000 to 190

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launch the eight MDGs, including MDG 4 on children’s health and MDG 5 on maternal health, the related MDG 6 on HIV/AIDS, malaria, and tuberculosis, and another on food security. At the beginning of 2010, MDG 4 and especially MDG 5 were the two goals the furthest from being achieved by the fast-approaching due date of 2015. Maternal mortality rates had remained essentially constant since 1990.21 The world was estimated to have reached 9% of the maternal health goal and 32% of the child mortality goal.20 The UN scheduled a special summit session on the MDGs in September 2010, giving a Muskoka initiative a subsequent near-term venue for full multilateral multiplication in the approval awarded and money mobilized. The evidence indicating the stalled MDGs, as well as the landing spot provided by the UN September meeting, encouraged Canada to make MNCH the centerpiece initiative of its Muskoka G8. It indicated a receptive place and a longer-term and broader political commitment to maternal and child health. G20 failure A fourth force propelling the Muskoka Initiative forward was the continuing failure of the G20 to act in the health field. Even as the UN alone seemed unlikely to meet its MDGs, it became clear that it would secure no support from the new G20 summit. The G20 had proclaimed at its Pittsburgh summit in September 2009 that it would henceforth serve as the world’s permanent, primary forum for its members’ international economic cooperation and offered general support, but no funding, for the MDGs as a whole.25 On January 12, 2010, its sherpas met in Mexico City to discuss the new G20’s relationship with the old G8, starting with Canada hosting the next G20 summit in Toronto, one day after its G8 Muskoka summit. G20 sherpas decided that the G20 would cover economics, leaving development largely to a G8 that now had to prove its continuing worth. During 2010, Korea, which was to host the G20 summit in November 2010, secured the support of Canada and others for a major initiative on development, but one that would involve mobilizing no new money and that would not focus on the MDGs.26 Further, the G20’s Toronto summit in June 2010, hosted by Harper, had as its major objective and achievement an agreement that advanced countries would reduce expenditures in order to control their mounting deficits and debt. The G8’s


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historic focus, fundraising, and achievements in development and health during the previous decade thus provided a proven platform on which to build, as well as expectations that the Muskoka summit could and would act in this field.27 Canada’s preparation as host Driven by these domestic societal and governmental pressures and by the failure of the UN and G20 to meet the already-agreed MNCH need, on January 20, 2010, Canada’s G8 team reaffirmed that the Muskoka summit agenda would include development with a focus on health, peace, and security; some aspects of climate change, probably financing for adaptation and mitigation; and economic issues, to a limited extent. That day, Embassy magazine ran an article titled “Putting the World’s Poor on the G8 Agenda” signed by the heads of the seven NGOs in the coalition.21 On January 24, it was authoritatively reported that Stephen Harper planned to make “aid for mothers and children in poor countries” and “child and maternal health” central summit themes.28 “Ottawa want[ed] to foster collaboration among the richest countries to improve hospitals and health care for mothers and newborns in poor countries. The federal government also want[ed] to set an example by increasing its own spending on maternal and child health in developing countries—although money [had] not yet been allocated for this effort.”28 A multi-stakeholder conference at the University of Toronto on January 25 on “Accountability, Innovation, and Coherence in G8 Health Governance: Seizing Canada’s G8 Opportunity” gave Canada’s G8 governors greater confidence that a maternal and child health initiative would receive widespread professional and civil society support. The CCMNCH20 published a background document for the conference, dated January 19 and entitled “The 2010 Muskoka Summit: An Opportunity for Canada to Lead on Preventing the Deaths of Women and Children.” It began by forging the link with food and agriculture, identifying the first causes of maternal, newborn, and child mortality as “malnutrition and preventable diseases,” with malnutrition as an “underlying cause of 30% of child deaths.” Its prescribed interventions included “access to an adequate diet for pregnant women and for children under two.” Its central requests were for G8 leaders to close the estimated annual $26.5 billion global gap to meet the


three health MDGs by 2015 and to create a global action plan on MNCH to help achieve MDGs 4 and 5. On January 26, the PMO issued a statement by Harper29 that was published as an op-ed in the Toronto Star, Canada’s largest-circulation daily newspaper. The article outlined his major summit initiative on MCNH. Its language closely resembled that used in the established global NGO campaign. The campaigners felt that their argument to highlight MNCH had been well received by the Canadian government, owing to the already established international network on the issue. One difference was that, initially, the global campaign had been more focused on children, whereas Harper’s G8 initiative was geared toward maternal health. On the same day, Canada’s development minister Bev Oda hosted a round table with members of the CCMNCH.30,31 Immediately after Harper’s announcement, Canada’s major opposition party, the Liberal Party, politicized the issue, arguing that Harper needed to include publicly funded abortions in the initiative. It suggested that, like George W. Bush when he was president of the United States, Harper sought to deny Canadian women’s abortion rights. These claims by Opposition Liberal Party leader Michael Ignatieff were echoed by his foreign affairs critic Bob Rae, who suggested that the Canadian government should push the governments of many African nations where abortion on demand was illegal, to adapt the very different policies that Canada had at home.30 These claims received much attention in the Canadian media. Nonetheless, this outburst of domestic partisan political division did not deter the Canadian government from driving its initiative ahead, even with its minority position in Parliament at the time. The international preparations for the summit and its proposed agenda started among the sherpas, foreign affairs sous-sherpas, and political directors early in 2010. The G8 sherpas met every month for the 5 months leading up to the summit. They were accompanied by the preparatory meetings of the Group of Seven (G7) finance ministers in Iqaluit in January and the G8 foreign ministers in Gatineau. In a meeting added to the preparatory schedule, G8 development ministers met in Halifax in April. There, the ministers continued to lay the foundations for the MNCH initiative. The health minister from Mali, as well as senior representatives from the Organisation for Economic Co-operation and


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Development (OECD), the UN, and the World Bank, contributed. Accountability and aid effectiveness, MNCH, and food security were the three issues discussed. The ministers supported the September 2010 UN high-level plenary on the MDGs as an opportunity for the international community to take stock of the progress to date.32 The business community contribution In the lead-up to the Muskoka summit, the business community’s contribution was late, limited, and supportive of the Canadian government and the civil-society coalition. Its initial involvement came only on January 28, 2010, when Harper gave the G8 host’s traditional address on summit priorities to the World Economic Forum in Davos, Switzerland, to the elite business and government actors assembled for their annual forum. Outlining his priorities and principles as host of both the G8 and G20 summits, Harper emphasized the need to start limiting government deficits and debt and to improve accountability in delivering the summit promises already made. At the end of his speech, he announced that “as president of the G8, Canada will champion a major initiative to improve the health of women and children in the world’s most vulnerable regions. There are indications that other members of the G8 share our concern and would be receptive to such a proposal.”33 This was the only passage of the speech that received spontaneous applause. Three months later, on April 28, 2010, the annual meeting of the Business Eight (B8) was held in Ottawa. In their “G8 Business Declaration,” the heads or representatives of the major business associations in all G8 members strongly called on their governments to engage urgently in deficit and debt reduction.34 Their interest in human health arose on only two occasions, neither of which focused on or affirmed the value of MNCH. The first reference was in regard to intellectual property, where the B8 noted that “infringements result in knockoffs that . . . all too often threaten health and safety.” The second was climate change, in the statement that “there must be a balance between addressing climate change, which includes the advancement of clean energy development, and other global priorities, such as poverty and disease eradication.” The B8’s reiteration of Harper’s call for deficit and debt reduction showed the lack of initial support the B8 had for the costly MNCH initiative. 192

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But this counter-pressure from the business community did not hold with a prime minister who had long personally respected the private sector’s priorities.35 By May 15, Canada’s G8 partners had begun to signal that they would make the financial contributions necessary to launch the fundraising needed to make the Muskoka Initiative a success. On the eve of the G8 summit, Harper again publicly highlighted his priority of MNCH, in the same words he had used at Davos.36 The strong views of the children-focused CCMNCH and the G8 development ministers thus prevailed over those of the most G8-focused business community at the Muskoka summit. The momentum from accountability and compliance Immediately before the summit, further momentum came from the high levels of compliance of Canada and some of its partners with their MNCHrelated commitment made at the 2009 L’Aquila summit,37 the commitment to accelerate progress on combating child mortality, including intensifying support for immunization, micronutrient supplements, maternal health, reproductive health care and services, and voluntary family planning. Canada complied fully. Full compliance also came from Japan and the United Kingdom, for an overall G8 average of 61%. On the commitment to address the scarcity of health workers, particularly in Africa, which was an important component of the delivery of MNCH, Canada achieved full compliance by introducing new initiatives and committing more funding to strengthen health systems.38 Full compliance also came from France, Japan, the United States, the United Kingdom, and the European Union, for an overall G8 average of 78%.37 For the Muskoka summit, Harper emphasized accountability and effectiveness across all G8 and G20 commitments, and on ODA in particular.39,40 Accountability had been addressed at the L’Aquila summit. In order to fulfill those promises, the Canadian government took the initiative to create the G8 Working Group on Accountability. A week before the 2010 Muskoka summit, on June 20, the G8 presidency released the “Muskoka Accountability Report: Assessing Action and Results against DevelopmentRelated Commitments.” It focused on 10 thematic areas: aid effectiveness; debt relief; economic


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development; health; water and sanitation; food security; education; governance; peace and security; and environment and energy.41 The Muskoka summit thus delivered its first health-related achievement before the leaders had even met. The “Muskoka Accountability Report” was the first ever comprehensive, systematic assessment identifying what the G8 had accomplished in keeping its development commitments. A critical component was making the new money mobilized by the summits more accountable and effective, in part through recipient country and community partnership, ownership, and a spirit of mutual accountability. The report found that Canada and most partners had fulfilled the G8’s 2005 commitment to double aid to Africa.41 This G8 report did not individually score each of the accumulated 56 development-related commitments or identify the individual G8 members’ delivery of them, but it did take stock of the accomplishments thus far and outlined areas where countries were lagging and where there was room for improvement. The Accountability Working Group responsible for the report acknowledged key criticisms of the G8, particularly the issues of double counting and the lack of transparency. It indicated that overall progress had been positive, “with some members meeting or surpassing their individual targets.”41 It stressed that the G8 was on track to meet its commitments to provide $60 billion to strengthen health systems and fight infectious diseases by 2012. The 2010 Muskoka communiqué issued a week later stated that regular accountability reports should be issued to take stock of the progress on future G8 commitments.42 At the summit Ultimately, leadership at all levels is fundamentally important for creating and sustaining momentum and for conversion of the momentum into results on the ground.43 This is especially true when the leaders of the world’s most powerful countries gather together alone in a compact club they consider their own. It is thus important to chart their face-to-face discussions to see how the Muskoka Initiative was ultimately achieved. Before the leaders’ collective discussions at Muskoka, several bilateral meetings were held on site. Harper met with Japanese Prime Minister Naoto Kan, British Prime Minister David Cameron,


and Italian Prime Minister Silvio Berlusconi. Their talks dealt with development, security, and relations with North Korea. This allowed for an at least implicit cross-issue area linkage, in which Harper supported his partners’ key priorities, such as North Korea’s recent sinking of a South Korean warship, in return for their support for the MNCH initiative to which Harper was now publicly attached as the defining issue by which his summit would be judged a success. The G8 leaders assembled at noon on June 25 for scheduled discussions on development and finance. They had an intimate discussion over dinner that evening. The next day, they met with African outreach leaders from Algeria, Ethiopia (chair of the New Partnership for Africa’s Development), Malawi (chair of the African Union), Nigeria, Senegal, and South Africa, particularly to discuss the Muskoka Initiative as a key component of Africa achieving the MDGs. They were later joined for the first time by leaders from Colombia, Haiti, and Jamaica to discuss regional and international security challenges. The African leaders were strongly supportive of Harper’s leadership on MNCH, as this was a critical development issue for them. After the opening luncheon discussion of the economy, focused on the issue of fiscal consolidation to respond to a new financial crisis erupting in Greece, the G8 leaders’ first substantial focus was on development, and specifically Harper’s top priority of MNCH. Each G8 member was asked to contribute new funding to MDGs 4 and 5 through existing mechanisms to scale up simple, proven instruments such as trained healthcare workers, vaccinations, nutrition, and clean water and to strengthen the healthcare systems that these interventions needed to succeed. In the end, all G8 leaders did, each providing enough to make the overall initiative appear as a collective success. The Muskoka MNCH achievements The MNCH initiative was the central achievement of the Muskoka summit. The Lancet labeled it “a welcome cornerstone of the summit’s work.”44 At Muskoka, health issues generally received 26% of the words in the concluding communiqués, and MNCH specifically received 18%. Those documents affirmed the principle that health and MNCH were linked to food and nutrition and to climate change, making a climate–health connection that UN


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summits had largely failed to make.45 The G8 at Muskoka made 10 commitments on health, heavily focused on the health MDGs. Within these commitments, the G8 mobilized $7.3 million to advance MNCH. Canada’s contribution totaled CA$2.85 billion over the following 5 years. This pledge consisted of CA$1.75 billion in a renewed commitment to continue previous funding and CA$1.1 billion in new money. Canada’s strong and early announcement before the official release of the statement encouraged other G8 members to contribute. In total, the G8 members pledged $5 billion over 5 years. The United States committed to $1.3 billion over 2 years. The United Kingdom donated about $300 million a year for 2 years. Germany contributed over $500 million and France about $400 million. Both France and Germany had been generous aid donors in the past. Italy contributed less. Russia reportedly promised $75 million over 3 years.46 Additional funding was promised by the non-G8 democratic countries of Korea, the Netherlands, New Zealand, Norway, Spain, and Switzerland. From civil society, the Bill & Melinda Gates Foundation and the United Nations Foundation also contributed, bringing the total of non-G8 contributions to $2.3 billion, and the total amount raised for the initiative to $7.3 billion.42 The summit thus took a substantial step forward to support its top priority of MNCH. It started to raise the $30 billion estimated by the UN to be necessary to save the lives of the 30 million children and 2 million mothers who would otherwise die unnecessarily by 2015. Altogether, the G8 leaders at Muskoka alone pledged enough new money to save the lives of an estimated 1.3 million children and 64,000 mothers. Moreover, in their final communiqué, leaders chose the strongest language of the possible wordings that had been proposed in the draft, affirming that “we will ensure follow-up on its recommendations.”42 This demonstrated a clear commitment from the leaders to fulfill their promises on these important development plans. Harper noted that, owing to the focus on accountability that year and in the future, G8 members might have been more conservative in making financial commitments this time, on the understanding that the amounts promised would also now have to be the amounts actually delivered. Another constraint on the amount promised was the commitment to medium-term fiscal consolidation that G8 194

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members were to announce at the G20 summit in Toronto the next day. NGOs, including Save the Children and Plan Canada, were disappointed with the total pledged, which fell short of the $30 billion the UN had estimated was needed to get the job done. Others noted that, at a time when overall ODA was flatlining, the new MNCH monies would be diverted from other important development domains.47 However, the G8 leaders also recognized that the $5 billion pledged on June 26 would not be sufficient. Thus, in their final communiqué, they noted the UN HighLevel Meeting on the MDGs that was coming up in September and called on all development partners to strengthen the collective resolve to accelerate progress toward the targets. This was a major advance in the development of global governance outside the G8, as the UN multiplied the Muskoka down payment to a pledged $40 billion altogether. In contrast to the G8 at Muskoka, the G20 Toronto summit made only one direct reference to health, promising to “strengthen social safety nets (such as public health and pension plans).”48 This was fewer than the three references to health made at the previous G20 summit in Pittsburgh.4,49 The Toronto G20 did offer substantial support for the healthrelated issues of aging populations, climate change, food security, the Global Pulse Initiative, and the Global Agriculture and Food Security Program. It also committed to meeting the MDGs by 2015, including through ODA. It endorsed the 2009 L’Aquila Food Security Initiative and created the Development Working Group. The G20 was thus generally supportive, but clearly relied on the G8 to lead on global health. The multilateral UN multiplication Following the Muskoka summit, work on achieving MDGs 4 and 5 continued as planned. A special high-level meeting on maternal and child health was convened at the annual UN General Assembly (UNGA) in September 2010. It was the second time in the history of UN summits that health was a stand-alone focus, following one on HIV/AIDS in 2001 and preceding one on the prevention and control of non-communicable diseases (NCDs) in September 2011.50 The meeting galvanized significant additional support from the international community, building on the G8 Muskoka Initiative. With the objective to save 16 million lives by 2015 in the


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world’s 49 poorest countries, the UN secretary general launched the Global Strategy for Women’s and Children’s Health.51 Under the global strategy, an estimated $40 billion over 5 years from a wide variety of global actors was mobilized.52 To advance the global strategy, the UN also created the Commission on Information and Accountability for Women’s and Children’s Health to determine the most effective global and national arrangements for global reporting, oversight, and accountability of women’s and children’s health.53 On December 16, 2010, Stephen Harper and Tanzanian president Jakaya Kikwete were named the commission’s co-chairs. Participants came from governments, international organizations, civil society, foundations, academia, and the private sector, which was now brought in at this extended, UNwide implementation stage. The commission was also supported by two working groups of technical experts: one to improve accountability to achieve results and the other to address the best way to ensure accountability of financial resources.53 Transparency and accountability were high on the commission’s agenda at its January 2011 meeting. The commission agreed that its main objective was to achieve transparency in both spending and in the collection of information. At the second and final meeting on May 2, 2011, it outlined 10 recommendations, each with a timetable and a suggested path for implementation. Aligned with the objectives, the recommendations focused on data-collection methods for maternal and child health information in an effort to improve resource allocation and outlined goals to develop a coordinated system for tracking spending on health.51 On the 1-year anniversary of the UN’s 2010 special meeting on maternal and child health and the launch of its global strategy, world leaders congregated at the September 2011 UNGA to measure progress, mobilize further support, and highlight the commission’s recommendations to accelerate progress on women’s and children’s health. Political momentum was sustained within the UN process by holding another issue-specific meeting and continuing the monitoring mechanism. G8 delivery Many civil society advocates were concerned that the momentum within the G8 would not be sustained long enough to produce real results. French


president Nicolas Sarkozy did not say he would keep MNCH on the agenda of the G8 summit that he would host in 2011. Moreover, France’s relatively low pledge of $400 million over 5 years at Muskoka indicated a limited French commitment to the Muskoka Initiative. Indeed, the 2011 Deauville summit produced only one maternal and child health commitment, a reiteration of the Muskoka Initiative that stated “we reaffirm our commitment to improving maternal health and reducing child mortality, most notably through the Muskoka Initiative for Maternal, Newborn and Child Health launched in 2010.”54 At the United States–hosted Camp David summit in 2012, there were no new advances on MNCH, merely a commitment to transparently report any progress on the initiative.55 Even less attention came under the United Kingdom’s G8 presidency in 2013, by which time dementia had become the G8’s focus in health. Without this sustained iterative attention from successive summits, the delivery of the Muskoka Initiative was low.56 The G8 Research Group’s assessed compliance with the MNCH commitment at the 2011 Deauville summit had a very low average score of 44.5%, which was far below the average of 77% for all priority commitments across all issue areas made in 2011. Only Canada, Germany, Russia, and the EU fully complied.57 At Muskoka, the G8 leaders had agreed to continue their accountability self-assessment the following year. The “Deauville Accountability Report: G8 Commitments on Health and Food Security: State of Delivery and Results” focused on maternal and children’s health and on the integrally related areas of food and nutrition, the signature initiatives of the previous 2 years.58 Both initiatives were multi-year funding commitments: the food security initiative with a commitment to disburse funds over 3 years and the Muskoka Initiative with money promised for 5 years. The Deauville report provided G8 member–specific information on how each member would allocate the MNCH funding and reiterated support for the recommendations of the Harper-Kikwete Commission.54 In addition to such G8 self-assessment, civil society and international NGOs undertook their own accountability assessments of a priority set of G8 commitments and those of the UN’s global strategy. The Partnership for Maternal, Newborn, and Child Health (PMNCH), a 500-member coalition under


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the World Health Organization (WHO), published annual reports tracking the implementation of the global strategy. At the 2013 UNGA, when leaders gathered to review progress on the MDGs, PMNCH released its third annual review, which assessed 293 partners. For the first time, these partners included the private sector — again at the implementation stage within the context of UN-based multilateral organizations. This collaboration mechanism under the umbrella of the WHO harnessed the strengths of the private sector to assist with the implementation of the Harper-Kikwete Commission recommendations and, more generally, the UN global strategy as a whole. Only in 2014, 1 year before the UN’s MDG deadline, did G8 compliance with its MNCH commitments begin to improve. At the 2013 Lough Erne summit, the G8 committed to ensure that investments had a measurable impact on malnutrition for women. Six months later, average compliance with this commitment was 78%, led by full compliance from Canada, France, Germany, Italy, the United Kingdom, and the EU. One apparent cause for this 2013–2014 surge was the link made between health and nutrition, as nutrition, food, and agriculture, in sharp contrast to health alone, had been a sustained priority for the summits in 2012 and 2013. The 2010–2012 plunge may be associated with the diversion of UN summit attention from the MDGs in 2010 to the largely competing health issue of NCDs in September 2011.50 It also suggests the inadequacy of the accompanying accountability mechanisms of both the G8 and UN. The personal accountability of leaders to one another, through their sustained attention to the same priority issue at successive summits, would seem to be the most effective approach. As with the rest of G8 governance, accountability and compliance seem to require attention and action at the very top. Conclusions The G8 Muskoka summit was a substantial success in governing MNCH, above all in the domains of decision making, money mobilized, and the development of global governance, even if there was a long lag in the robust delivery of the relevant commitments. This success, surprising at a time of financial crisis and consequent fiscal consolidation, stemmed from the influence of a Canadian-led, in196

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ternationally supported coalition of NGOs focused on children and development overall, supportive Canadian public opinion, and advocates among officials within the host Canadian government and the UN system. They were able to overcome the resistance of a business community pressing for fiscal consolidation and opposition parties in Canada that opposed the MNCH initiative that Prime Minister Harper’s minority government advanced. Also important to the success of the Muskoka summit was the distinctive dynamic at the G8 summit, where the leaders of the democratic members and participants could come together to support the hosts’ and other members’ priorities, to produce a collective success for all. This particular configuration of causally salient actors and forces suggests how the concert-equality model of G8 governance should be refined. First, it shows that shocks in the same subject area, in this case MNCH, are not necessary for summit success. It also shows that the inhibiting and diversionary shocks in other areas—notably the 2008 and 2010 financial crises that fuelled an emphasis on fiscal consolidation and the 2009 food crisis—can be offset or overcome to mobilize major monies to meet key global health needs. Second, it confirms that the failure of the multilateral organizations of the UN system, including UNGA as the guardian of the MDGs and WHO as the core functional organization for global health, do indeed require and call forth the leadership and capabilities of the major democratic powers assembled in the G8 to reduce gaps. The newer summits of the less democratically composed G20 and the BRICS summit did not take up the cause, with the former focusing on different issues in and approaches to development and the latter focusing on a distinctive array of health issues rather than MNCH.49,59 Moreover, other issue-specific entities within the disparate UN galaxy, notably UNICEF, offered useful support. Summits stand out as important at the UN itself. The 2000, 2010, and 2015 MDG summits gave the Muskoka summit, respectively, a globally defined goal, an early opportunity for magnification of the Muskoka monies, and an incentive to delay implementation until the 2015 deadline drew near. Moreover, the 2011 UN summit on NCDs, which were absent from the MDGs, diverted attention from the MNCH cause.


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Third, it shows that even with the rapid rise of the leading emerging powers—gathered in the G20 and BRICS but not the G8—G8 members, including the EU, still provide two-thirds of the world’s ODA and other specialized capabilities critical for global health.60 The spread of democracy to important African countries and the participation of their democratically elected leaders in the G8 Muskoka summit further fuelled its achievements on MNCH. Fourth, domestic political cohesion as a cause of G8 summit performance can take the form of bottom-up civil society pressure, rather than the top-down political control, capital, continuity, personal commitment, and issue-specific competence the host and other leaders have to the featured cause. In this bottom-up process, NGOs led, including those with a faith-based orientation such as World Vision, while the business community was initially opposed and shifted to support only at a subsequent stage. However, at Muskoka, the additional monies mobilized by the Gates Foundation and the UN Foundation show the continuing relevance of the business community in its traditional philanthropic role. Three questions remain for future research, and they are also of central importance in the policy world. The first concerns causality. The G8 Muskoka Initiative raised the resources intended to prevent 1.3 million deaths of children under 5 years of age, prevent 64,000 maternal deaths, and enable access to family-planning methods for 12 million couples. With the additional financial and organizational support catalyzed under the UN’s global strategy, the estimated number of individuals to be affected increased to 16 million in 49 countries by 2015.61 Before the MNCH initiative began to be prepared, World Bank data showed that MDG 4 was only 32% and MDG 5 only 9% of the way to being met.62 Three years after the Muskoka summit, the MDG 4 target for infant mortality was 59% met, the target for under-5 child mortality 62% fulfilled, and MDG 5 on maternal health 63% achieved.63 This was a significant advance in 3 years—27% for MDG 4 and 54% for MDG 5. In the 4 years following the Muskoka summit, from 2010 to 2014, child and maternal death rates declined faster than ever before.64 These strong advances cannot confidently be attributed the Muskoka Initiative alone, especially as G8 members’ compliance with their relevant commitments was quite low before 2013–2014 as the


MDG deadline approached. Moreover, the MNCH work of earlier G8 summits, the UN, civil society actors, and recipient governments all had relevant roles, especially given the time it takes for money mobilized by actors to make a discernable difference to health outcomes among difficult conditions in the field. Indeed, a study of the compliance of G20 members with their development and employment commitments made at the Seoul Summit in November 2010 shows that, when members are given more time to implement than the 1-year period until their next summit, compliance with their commitments rises.65 In particular, the impact of other international institutions, starting with the WHO and the ongoing program of the well-resourced Gates Foundation, should be traced in detail to help fill the causal process-tracing gaps. Yet the match between the input of the Muskoka Initiative and the improvement in MDG 4 and 5 outcomes three years later were sufficiently close to support a call for the now G7 to return to the MNCH cause for a final push in 2014 and 2015 to close the remaining gaps to meeting these MDGs in full. The international Saving Every Woman Every Child: Within Arm’s Reach Global Health Summit that Harper mounted in Toronto on May 28–30, 2014, just before the G7 summit in Brussels on June 4–5, suggested that steps in this direction were underway. The second question concerns accountability and its impact on improving or inhibiting the implementation of the MNCH commitments made at Muskoka and at the UN summit in September 2010. None of the different forms of accountability mechanisms used at the G8 or UN appears to have rapidly increased members’ compliance with their Muskoka MNCH commitments. This suggests that accountability mechanisms controlled by those who made the commitments have their limits, while those controlled by independent outsiders with no specific stake in the result could have a more potent positive effect. A further possibility is to design a process so that leaders at subsequent summits can fully assess their own and their peers’ compliance with the previous commitments they have made. The third question is how to involve the business community in a much more robust way, to help improve the MNCH and the closely related MDGs. It would be instructive to conduct a cross-case comparison with recent G8 initiatives in nutrition, food, and agriculture, where the private


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sector is much more integrally involved at the start, and where commitments and compliance by G8 members are strong. The G8 produced 12 health and two food/agriculture commitments in 2010 but two health commitments and 12 food-agriculture commitments by 2013. During this time, G8 members complied with their assessed food/agriculture commitments at an average of 70%. Among the many contributions that business makes to designing and implementing these commitments, serving as a somewhat independent source of accountability assessment could be an important one.

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Conflicts of interest The authors declare no conflicts of interest.

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Introduction to the yogurt in nutrition initiative and the First Global Summit on the health effects of yogurt.

Founding of the Global Health Film initiative.

Impact of global health governance on country health systems: the case of HIV initiatives in Nigeria.

Environmental Influences on Maternal and Child Health.

Prioritizing research for integrated implementation of early childhood development and maternal, newborn, child and adolescent health and nutrition platforms.

Facilitators and barriers to quality of care in maternal, newborn and child health: a global situational analysis through metareview.