Although Afnan Holmes and colleagues report covers

Although Afnan-Holmes and colleagues\' report covers substantial ground, several issues remain unexamined. For example, why have facility delivery rates in the country stagnated at roughly 50% over the past decade? Although enhancement of women\'s agency in making health-care decisions is necessary, so is an improved understanding of the role of communities, of men and older women, and of traditional birth attendants. These actors have a powerful role in promoting or denying opportunities for effective care and therefore good health outcomes. Subnational analysis is needed to identify barriers related to geography and cultural and economic factors. Other contextual issues, such as quality of roads, transport, and communication, were omitted from the analysis but surely play a large part in enabling access to care.
Tracking of spending on reproductive, maternal, newborn, and child health (RMNCH) is key to monitoring progress towards Millennium Development Goals (MDGs) 4 and 5 to reduce child mortality and improve maternal health. The Organisation for Economic Co-operation and Development\'s development assistance committee tracks bilateral and multilateral official development assistance (ODA) and other resource flows, including private donors, such as the Bill & Melinda Gates Foundation—so-called ODA+—under the credit reporting system database. Commitments and disbursements are tracked at both the aggregate level and at the level of particular aid programmes. The importance of measurement of progress and ensuring accountability has been increasingly discussed after the Paris Declaration on Aid Effectiveness. Within this aniracetam context, in this issue of the new study by Leonardo Arregoces and colleagues is the latest in a long series of analyses on resource tracking of RMNCH, focusing on evaluating whether donor funding is well targeted to countries with the greatest need. In their comprehensive study, Arregoces and colleagues report that, although overall levels of ODA+ funding decreased, funding for RMNCH increased in 2011 and 2012. External resources still account for 16·4% of total health spending in low-income countries and 9·5% in countries in Africa. This finding has implications for the sustainability and fungibility of programmes and is vital to better understand the trend of the sources and level of supports. Despite a wealth of research based on available datasets, questions remain regarding the fragmentation of funding: how should aid be disbursed? What modality and approaches are most effective—eg, project-oriented, general budget, or multisectoral in terms of outcomes and outputs? What is the linkage between disbursement and actual spending? This study provides a useful contribution to whether programme specific-funding has been targeted to those countries with the greatest needs. Yet there remains room for more international efforts to further investigate the aforementioned questions. The study by Arregoces and colleagues raises the importance of harmonising international collaboration across various resource-tracking initiatives. This is welcome and highlights the need to fill existing gaps and agree on a standardised method. The current credit reporting system method broadly categorises each fund and has limits as to different health-care activities—for example, prevention and treatment of HIV/AIDS among pregnant women can be either categorised under maternal health or HIV/AIDS programmes. On the other hand, the Institute for Health Metrics and Evaluation excludes malaria, tuberculosis, and HIV/AIDS programmes from its estimate on aid for maternal, newborn, and child health. The assumptions around the allocation to RMNCH from general budget support could also be worthy of further examination. There is no doubting the importance of ODA in health generally, and more specifically for RMNCH. Countries and external funds have competing priorities in allocating restricted funds. It is also important to ensure comprehensiveness, and the study rightly raises the issue of some of the data gaps. Efforts should be made to include all missing data, wherever possible, from countries that are not members of the development assistance committee (such as China and Middle Eastern countries), major donor non-governmental organisations, and foundations, to ensure that public and private influences on the direction of ODA programmes are properly understood. For example, China contributes as much as US$4 billion in aid annually and is increasingly influential in Africa, but was not included in this study. On a similar note, understanding the roles of both external and domestic funding is vital—more than half of all RMNCH funding for the 75 Countdown countries comes from domestic sources.