Ideas to Action:

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Views from the Center


This is a joint post with Katherine Douglas.

One of the exciting things about the Cash on Delivery Initiative is that once people understand the concept, they frequently come up with all kinds of new ideas for applying it. This happened most recently at the CGD-hosted book launch for Cash on Delivery: A New Approach to Aid this week. Within the course of an hour, the conversation shifted from skeptical questions to prospective applications of COD Aid.   While the book outlines a proposal for channeling aid to countries that accelerate their progress toward accomplishing the Millennium Development Goal of universal primary completion, people have asked about applying it to water, deforestation, malaria and to another Millennium Development Goal: reducing maternal mortality.

This last suggestion has struck a chord with many of us.  Every year, more than half a million women die from complications in pregnancy and childbirth, and 99% of these deaths occur in poor countries.  What’s more, as Karen Grepin recently discussed (citing the Disease Control Priorities Project), counting stillbirths among infant deaths would mean that roughly half of all child mortality occurs in the first year of life. These deaths are largely preventable.  Compelling evidence from Sri Lanka, Tunisia and Malaysia reveals that maternal and infant mortality can be drastically reduced in low-income settings by increasing access to skilled attendants and emergency obstetric care at birth. And if this isn’t reason enough to support the idea, consider this: interventions aimed at expanding coverage of skilled birth attendance demand basic reforms to strengthen health systems, improving health training, assuring availability of medical supplies, and addressing problems in management and contracting. Julio Frenk, Mexico’s former Health Minister, made this point at a recent Woodrow Wilson Center event, arguing that setting priorities grounded in women’s health drove improvements in Mexico’s health system.

So what would happen if a group of funders offered to pay $25 for a proxy indicator closely related to reducing maternal mortality – such as the number of births attended by a skilled health worker?  (As we emphasize in the book, defining the right indicator is critical.  It must be clear, measurable and verifiable at reasonable cost. An initial step would be to confirm whether skilled birth attendance is the right measure.)

To make a credible COD Aid agreement, this indicator would be reported by the recipient government and then subjected to verification by an independent agent – perhaps through a combination of auditing the reporting process and conducting a separate survey. One of the key advantages of such an agreement is that it would let the government decide the course of action it thinks would best achieve progress. The agreement would also align incentives at the national level toward the goal, involving the Finance Ministry as much as the Health Ministries in the process. It would also give a strong boost to improving vital registration and data on births and maternal mortality. 

It is actually a good time for such an initiative. This week, African leaders announced the theme of their July 2010 summit in Kampala:  “Maternal, Infant and Child health and Development in Africa”.  In addition, Canada is hosting the G-8 in Toronto this June and Prime Minister Harper announced that he would like to make maternal and child health a top priority for that meeting. If the G-8 agreed to develop a joint initiative to reinvigorate the MDG on reducing maternal mortality by expanding skilled birth attendance, a COD Aid agreement could probably be designed and in place within a year. At one of our workshops on COD Aid, a participant described the idea as “MDGs with teeth.” Wouldn’t it be nice to have something like this at a G-8 meeting to sink our “teeth” into!


CGD blog posts reflect the views of the authors drawing on prior research and experience in their areas of expertise. CGD does not take institutional positions.