Analysis Women’s, Children’s, and Adolescents’ Health

Towards a new Global Strategy for Women’s, Children’s and Adolescents’ Health

BMJ 2015; 351 doi: http://dx.doi.org/10.1136/bmj.h4414 (Published 14 September 2015) Cite this as: BMJ 2015;351:h4414
  1. Marleen Temmerman, director1,
  2. Rajat Khosla, human rights adviser1,
  3. Zulfiqar A Bhutta, director23,
  4. Flavia Bustreo, assistant director general4
  1. 1Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland
  2. 2Centre for Global Child Health, Hospital for Sick Children, Toronto, Ontario, Canada
  3. 3Centre of Excellence in Women and Child Health, Aga Khan University, Pakistan
  4. 4Family, Women and Child Health Cluster, World Health Organization, Geneva
  1. Correspondence to: R Khosla khoslar{at}who.int

We know what needs to be done, say Marleen Temmerman and colleagues, but we need to push hard now to create a world in which every women, every child, and every adolescent is able to survive, thrive, and transform

The year 2015 marks a defining moment for the health of women, children, and adolescents. It is the end point of the United Nations’ millennium development goals, and their transition to the sustainable development goals, and also the 20th anniversary of the International Conference on Population and Development’s plan of action and the Beijing Declaration and platform of action.

This is a moment of reflection as well as celebration. Although great strides have been made in reducing maternal and child mortality, showing that change is possible, many countries are lagging behind in reaching millennium development goal 4 (to reduce the under 5 mortality rate by two thirds between 1990 and 2015) and goal 5 (to reduce the maternal mortality ratio by three quarters between 1990 and 2015 and achieve universal access to reproductive healthcare by 2015), and there are vast inequities between and within countries. In 2010, confronted with unacceptably high rates of maternal and child mortality, the UN secretary general called on the world to develop a strategy to improve maternal and child health in the world’s poorest and high burden countries, starting with 49 low income countries.

The 2010 Global Strategy for Women’s and Children’s Health was a bellwether for a global movement and led to significant progress worldwide in women’s and children’s survival and health. The Every Woman Every Child movement that grew out of the Global Strategy mobilised stakeholders in all sectors to work towards shared goals. It fostered national leadership, attracted new resources and financial commitments, and created a worldwide movement of champions for the health and wellbeing of every woman and every child.

Good progress has been made towards realising the vision to end all preventable maternal, newborn, and child deaths within a generation. Millions of lives have been saved, and progress towards the health related millennium development goals was accelerated. Child mortality fell by 49% and maternal mortality by 45% between 1990 and 2013. Strides forward were made in areas such as access to contraception and maternal and child health services, skilled attendance at births, reduced malnutrition, newborn interventions, management of childhood illnesses, immunisations, and combating HIV and AIDS, malaria, and tuberculosis.

The new strategy

The new Global Strategy for Women’s, Children’s and Adolescents’ Health, released this month (see box), builds on lessons learnt and new evidence and focuses on critical population groups, such as adolescents and women and children living in fragile and conflict settings. Its key objectives are to support the resilience of health systems, to improve the quality of health services and ensure equitable coverage, and to work with health enhancing sectors (such as education, water and sanitation, and nutrition).

As we start to define the sustainable development goals and related targets, we must increase the momentum in women’s, children’s, and adolescents’ health. Equally important is the protection and sustenance of often fragile gains in some countries, the importance of which became clear with the Ebola virus disease epidemic and its results: weak health systems for maternal and child health in west Africa became weakened further.

Stages in updating the Global Strategy

  • Initiative was led by the UN secretary general and World Health Organization, together with Health 4+ (the joint UN agency partnership to improve women’s and children’s health) and the Partnership on Maternal, Newborn and Child Health

  • WHO led the development of papers by expert working groups in key areas

  • Fifteen working papers were developed through online consultation and input from experts

  • A multistakeholder writing group was constituted

  • Consultations took place with member states and stakeholders in Geneva, New Delhi, and Johannesburg

  • Online consultation with public on zero draft of the Global Strategy

  • New Global Strategy launched at UN General Assembly in September 2015

  • Operational framework for the new Global Strategy due to be presented at World Health Assembly in May 2016

Successes, lessons, gaps, and emerging priorities

The 15 papers in this collection are the bedrock on which the new strategy is developed. They summarise the current state of evidence and underscore successes as well as critical gaps in progress, emerging priorities, and the key interventions needed for a new generation of women, children, and adolescents.

Based on a life course approach of interventions and a goal of universal health coverage, the papers highlight the critical interventions needed to ensure that women, children, and adolescents are able to survive, thrive, and transform. Their analysis is based on a synthesis of evidence from epidemiological and health data on effective strategies and interventions to realise the health and human rights of women, children, and adolescents around the world.

A key success of the past two decades has been the global reduction of child mortality by 49% and maternal mortality by 45%. However, much more needs to be done. Each day 800 women and 7700 newborns die from complications during pregnancy and childbirth and from other neonatal causes, and 7300 women experience a stillbirth. While important gains have been registered since the launch of the 2010 Global Strategy, women, children, and adolescents around the world continue to experience serious violations of their health and of health related human rights.1

One of the key factors behind the reduction of maternal and child mortality has been improved access to essential interventions and services. Family planning, antenatal care, delivery at facilities, and skilled birth attendance have all increased over the past two decades. However, huge inequities in coverage and quality continue, and furthermore stronger effort is needed to remove barriers to access, which continue to impede success.2 3

In particular, postnatal care for mothers and newborns has not received due attention and remains a missed opportunity in reproductive, maternal, newborn, and child health. Investments in women’s health beyond reproductive health needs greater attention, given the rise of effects on health related to non-communicable disease, such as cancer, obesity, and diabetes.

But substantial progress has been made in preventing HIV among neonates, thanks to programmes to prevent transmission from mother to child. Another success is the increase in the prevalence of exclusive breast feeding and of oral rehydration therapy, though further effort is needed to increase coverage. Deaths of children aged under 5 years remain high in sub-Saharan Africa and southern Asia, and many more children’s lives could be saved through the equitable scale-up of available, cost effective interventions. A broader and holistic global agenda on child health is needed that retains the aim to end preventable deaths among under 5s while being able to deal with emerging priorities and to achieve sustainable gains among school age children.

Evidence shows that interventions that are particularly effective in the areas of reproductive, maternal, newborn, and child health are family planning, management of labour and delivery, care of preterm births, breast feeding, and treatment of serious infectious diseases and acute malnutrition

The new Global Strategy also needs to pay attention to adverse experiences in early childhood that can increase the risk of poor social and health outcomes such as low educational attainment, economic dependency, increased violence, crime, and substance abuse, poor mental health, and a greater risk of adult onset non-communicable diseases such as obesity, cardiovascular disease, and diabetes.

Paradigm shift

The evidence is clear: investment in childbirth and delivery can quadruple returns in terms of women’s and newborn’s lives saved and stillbirths and disabilities reduced.4 The papers in this supplement underline the imperative to accelerate momentum and protect the gains made while also calling for innovative thinking and cutting edge research and approaches to meet the needs and aspirations of millions of women, children, and adolescents around the world.

Work on creating a new paradigm for women’s, children’s, and adolescents’ health will need to be done in a range of areas, such as sexual and reproductive health and rights, communicable and non-communicable diseases (including cancers), and mental health—all based on a life course approach. The targets identified in the sustainable development goals,5 together with the transformative agenda envisioned in the new Global Strategy to ensure that women, children, and adolescents survive, thrive, and transform, are the impetus to create a paradigm shift within a generation.

This vision necessitates a comprehensive approach that takes into account the structural determinants of health, tackles inequities in access to healthcare, and encourages accountability. Despite decades of unprecedented medical advances and innovations in healthcare, the quality of care in general—and of women’s, children’s, and adolescents’ health in particular—is often weak. Building on and extending this unfinished agenda, the papers in this collection elaborate the actions needed to improve health and wellbeing of women, children, and adolescents around the world.

A “grand convergence” is well within our reach.6 Given political momentum, and with the existing evidence, we now have the opportunity to end preventable deaths among all women, children, and adolescents, to vastly improve their health, and to bring about the transformative changes needed to fully realise their human rights and build resilient and prosperous societies.

We know what needs to be done. With a concerted effort we can eliminate wide disparities in preventable mortality and morbidity. In particular, by improving access to essential health interventions and building resilient health systems, we can achieve the grand convergence within a generation and create a world in which no woman, child, or adolescent faces a greater risk of preventable death just because of where they live.

The new Global Strategy is central to the realisation of this objective. It provides a platform for completing the unfinished work of the health related millennium development goals and to help countries implement the post-2015 development agenda and the health related sustainable development goals and targets.

A vision for the future

Despite some progress, societies are still failing women, children, and adolescents, most acutely in poor countries and among the poorest communities in all countries. We will fail in our endeavours if we do not comprehensively address everyone’s health needs. Women, children, and adolescents who are marginalised suffer from various inequities and discrimination, such as those based on gender, income, age, place of residence, and education levels, resulting in worse health outcomes. Low and middle income countries can have2:

  • Up to three times more pregnancies among teenage girls in rural and indigenous populations than in urban populations

  • A difference of up to 80% between the richest and poorest people in the proportion of births attended by skilled health personnel

  • A gap of at least 18% between the poorest and richest people in the proportion who seek care for children with pneumonia symptoms, and

  • A difference of least 25% in antenatal care coverage (of at least four visits) between the most and least educated and between the richest and poorest.

The papers in this supplement highlight three key areas of priorities for the new Global Strategy: the health needs of adolescents, multisectoral response, and emergency situations.

Meeting health needs of adolescents

A critical new priority at the heart of the new Global Strategy is the focus on adolescents. Adolescents aged 10-19 years have specific needs and require a responsive health system that takes into account their biological, emotional, and social development. Ensuring their healthy development means making the health system work for adolescents. But it also requires a focus on social risk factors as well as on the factors that can offer a protective effect across various health outcomes. This focus includes the legal and policy environment.

To realise the health and wellbeing of adolescents and protect their human rights, countries need to adopt holistic health policies and education programmes about prevention of injuries, violence, and self harm; good sexual and reproductive health outcomes; prevention of non-communicable disease; and other crucial aspects of physical and mental health and development. Such education will help adolescents enhance judgment and learn the skills to maximise their health and wellbeing.

A multisectoral response

Another distinguishing feature of the new Global Strategy is its explicit focus on the role of health enhancing and health enabling sectors. The evidence provided throughout this supplement highlights the importance of such interventions in the articulation of a comprehensive approach to health.

Attention needs to be paid to strengthening health systems’ response. Weak capacity in health systems and the health workforce, gaps in infrastructure, and a “verticalised” focus on biomedical aspects of health interventions hinder the attainment of health goals. Health system resilience, conversely, hinges on institutional capacity and human capital to adapt and respond to emerging shocks and needs. And policy and operational systems need to ensure continuing capacity to deliver essential health services equitably, even during an emergency, including by building greater self reliance among communities.

Innovation and financing are central to this new vision for women’s, children’s, and adolescents’ health. There is an urgent need to scale up innovations in a sustainable manner. Crucially, we also need to transform the financing landscape, by supporting the value for money agenda; to foster an integrated approach to complete the unfinished agenda on child health; and to break down the silos separating the flows of financing between women, children, and adolescents. Better mechanisms are needed for financing the health of women, children, and adolescents who live in conflict or post-conflict settings. And we need to foster innovative financing models at global, regional, and national levels.

Humanitarian crises and emergencies

Critical new evidence points to the importance of paying urgent attention to emergencies. Specific vulnerabilities of women, children, and adolescents living in humanitarian crisis settings threaten their health and wellbeing and the realisation of the Global Strategy. Though it is clear that humanitarian crises put women, children, and adolescents at grave risk, national planning processes often leave humanitarian preparedness, response, and recovery out of their longer term development planning.7

Increasing investment in women’s, children’s, and adolescents’ health has many benefits: it reduces poverty; it stimulates economic productivity and growth; it creates jobs; it is cost effective; and it helps women, children, and adolescents realise their basic human rights to health, wellbeing, and a sustainable future.

Conclusions

Implementation of the new Global Strategy depends on effective and independent accountability. However, the reality is very different. Several countries still do not have systems of civil registration and vital statistics monitoring or functioning national health accounts and information systems. To ensure accountability, a minimum standardised reporting system is needed that enables comparison of progress across countries and regions. Such a system would also strengthen national capacity and ensure an inclusive process for stakeholders. Furthermore, indicators recommended by the 2011 Commission on Information and Accountability need to be augmented to encompass the much broader agenda of the 2015 strategy, including human rights. The critical role played by UN agencies, academia, and consortiums such as Countdown to 2015 in the accountability process for millennium development goals 4 and 5 must be recognised.8 In the new Global Strategy we need to further strengthen this process, with an eye on country level accountability and action, and also ensure alignment between global and national levels of accountability and monitoring.

The new Global Strategy gives us a once in a lifetime opportunity to change the discourse regarding the health of women, children, and adolescents. It is clear that business as usual will not work. For women, children, and adolescents around the world to survive, thrive, and transform, we need transformative actions that will result in enormous social, demographic, and economic benefits. This is a vision that can unite us all: united we stand, divided we fall.

Notes

Cite this as: BMJ 2015;351:h4414

Footnotes

  • Numerous partners from governments, UN Agencies, CSOs, and academia have contributed to the development of this supplement and the overall Global Strategy, and the authors would like to express their thanks to all of them.

  • Contributors and sources: All authors wrote the manuscript, and all have read and agreed to the final version. MT is guarantor.

  • Competing interests: We have read and understood BMJ’s policy on declaration of interests and have no relevant interests to declare.

  • Provenance and peer review: Not commissioned; externally peer reviewed.

  • The authors alone are responsible for the views expressed in this article, which does not necessarily represent the views, decisions, or policies of WHO or the institutions with which the authors are affiliated.

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References

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