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BMJ 351:Suppl1

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

BMJ 351:Suppl1 TOWARDS A NEW GLOBAL STRATEGY FOR WOMEN’S, CHILDREN’S AND ADOLESCENTS’ HEALTH ­ TOWARDS A NEW GLOBAL STRATEGY FOR WOMEN’S, CHILDREN’S AND ADOLESCENTS’ HEALTH 1 Towards a new Global Strategy for Women’s, Children’s and Adolescents’ Health Marleen Temmerman, Rajat Khosla, Zulfi qar A Bhutta, Flavia Bustreo 4 Women’s health priorities and interventions Marleen Temmerman, Rajat Khosla, Laura Laski, Zoe Mathews, Lale Say BMJ 351:Suppl1 10 Children’s health priorities and interventions EDITORIAL OFFICES The Editor, The BMJ Wilson M Were, Bernadette Daelmans, Zulfi qar A Bhutta, Trevor Duke, Rajiv Bahl, Cynthia Boschi-Pinto, BMA House, Tavistock Square London, UK, WC1H 9JR Mark Young, Eric Starbuck, Maharaj K Bhan Email: [email protected] Tel: + 44 (0) 20 7387 4410 Fax: + 44 (0) 20 7383 6418 15 Realising the health and wellbeing of adolescents BMJ - Beijing Laura Laski on behalf of the Expert Consultative Group for Every Woman Every Child on Adolescent Health A1203 Tian Yuan Gang Center East 3rd Ring North Road 19 Ending preventable maternal and newborn mortality and stillbirths Chaoyang District Beijing 100027 Doris Chou, Bernadette Daelmans, R Rima Jolivet, Mary Kinney, Lale Say on behalf of the Every Newborn China Telephone: +86 (10) 5722 7209 Action Plan (ENAP) and Ending Preventable Maternal Mortality (EPMM) working groups BMJ - Hoboken BMJ Publishing Inc 23 Eff ective interventions and strategies for improving early child development Two Hudson Place Hoboken, NJ 07030 Bernadette Daelmans, Maureen M Black, Joan Lombardi, Jane Lucas, Linda Richter, Karlee Silver, Tel: 1- 855-458-0579 email [email protected] Pia Britto, Hirokazu Yoshikawa, Rafael Perez-Escamilla, Harriet MacMillan, Tarun Dua, BMJ - Mumbai Raschida R Bouhouch, Zulfi qar A Bhutta, Gary L Darmstadt, Nirmala Rao 102, Navkar Chamber, A Wing Marol, Andheri - Kurla Road Andheri (East) Mumbai 400059 27 Nutrition and health in women, children, and adolescent girls Tel: +91 22-40260312/13/14 Email: [email protected] Francesco Branca, Ellen Piwoz, Werner Schultink, Lucy Martinez Sullivan BMJ - Noida Mindmill Corporate Tower 32 Improving the resilience and workforce of health systems for women’s, 6th Floor, 24 A, Film City Sector 16 A Noida 201301 children’s, and adolescents’ health Telephone: + 91 120 4345733 - 38 James Campbell, Giorgio Cometto, Kumanan Rasanathan, Edward Kelley, Shamsuzzoha Syed, Email: [email protected] Pascal Zurn, Luc de Bernis, Zoe Matthews, David Benton, Odile Frank, Andrea Nove BMJ - Singapore Suntec Tower Two 9 Temasek Boulevard, #29-01 Singapore 038989 36 Ensuring multisectoral action on the determinants of reproductive, maternal, Tel: +65 3157 1399 Email: [email protected] newborn, child, and adolescent health in the post-2015 era BMJ - Sydney Kumanan Rasanathan, Nazneen Damji, Tesmerelna Atsbeha, Marie-Noel Brune Drisse, Austen Davis, Australia Telephone: +61 (0)2 8041 7646 Carlos Dora, Azza Karam, Shyama Kuruvilla, Jacqueline Mahon, Maria Neira, Eugenio Villar, Email: [email protected] Deborah von Zinkernagel, Douglas Webb Twitter: Follow the editor, Fiona Godlee @fgodlee and The BMJ at twitter.com/bmj_latest 42 Human rights in the new Global Strategy Indexing The BMJ The BMJ is an online journal and we therefore recommend that you Jyoti Sanghera, Lynn Gentile, Imma Guerras-Delgado, Lucinda O’Hanlon, Alfonso Barragues, Rachel index content from thebmj.com rather than this print edition. 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TTheBMJ_351_Supplement_TOC.inddheBMJ_351_Supplement_TOC.indd 1 001/09/151/09/15 5:475:47 PMPM ­ Women’s, Children’s, and Adolescents’ Health

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

he year 2015 marks a defining tary general called on the world to develop a important is the protection and sustenance moment for the health of women, strategy to improve maternal and child of often fragile gains in some countries, the children, and adolescents. It is the health in the world’s poorest and high bur- importance of which became clear with the end point of the United Nations’ den countries, starting with 49 low income Ebola virus disease epidemic and its results: millennium development goals, countries. weak health systems for maternal and child andT their transition to the sustainable devel- The 2010 Global Strategy for Women’s and health in west Africa became further opment goals, and also the 20th anniversary Children’s Health was a bellwether for a ­weakened. of the International Conference on Popula- global movement and led to significant prog- tion and Development’s plan of action and ress worldwide in women’s and children’s Successes, lessons, gaps, and emerging the Beijing Declaration and platform of survival and health. The Every Woman Every priorities action. Child movement that grew out of the Global The 15 papers in this collection are the bed- This is a moment of reflection as well as Strategy mobilised stakeholders in all sec- rock on which the new strategy is developed. celebration. Although great strides have tors to work towards shared goals. It fostered They summarise the current state of evidence been made in reducing maternal and child national leadership, attracted new resources and underscore successes as well as critical mortality, showing that change is possible, and financial commitments, and created a gaps in progress, emerging priorities, and the many countries are lagging behind in reach- worldwide movement of champions for the key interventions needed for a new genera- ing millennium development goal 4 (to health and wellbeing of every woman and tion of women, children, and adolescents. reduce the under 5 mortality rate by two every child. Based on a life course approach of inter- thirds between 1990 and 2015) and goal 5 (to Good progress has been made towards ventions and a goal of universal health cov- reduce the maternal mortality ratio by three realising the vision to end all preventable erage, the papers highlight the critical quarters between 1990 and 2015 and achieve maternal, newborn, and child deaths within interventions needed to ensure that women, universal access to reproductive healthcare a generation. Millions of lives have been children, and adolescents are able to sur- by 2015), and there are vast inequities saved, and progress towards the health vive, thrive, and transform. Their analysis is between and within countries. In 2010, con- related millennium development goals was based on a synthesis of evidence from epide- fronted with unacceptably high rates of accelerated. Child mortality fell by 49% and miological and health data on effective strat- maternal and child mortality, the UN secre- maternal mortality by 45% between 1990 and egies and interventions to realise the health 2013. Strides forward were made in areas and human rights of women, children, and such as access to contraception and maternal adolescents around the world. Stages in updating the Global Strategy and child health services, skilled attendance A key success of the past two decades has • Initiative was led by the UN secretary general at births, reduced malnutrition, newborn been the global reduction of child mortality and World Health Organization, together with interventions, management of childhood ill- by 49% and maternal mortality by 45%. Health 4+ (the joint UN agency partnership to nesses, immunisations, and combating HIV However, much more needs to be done. Each improve women’s and children’s health) and and AIDS, malaria, and tuberculosis. day 800 women and 7700 newborns die from the Partnership on Maternal, Newborn and complications during pregnancy and child- Child Health The new strategy birth and from other neonatal causes, and • WHO led the development of papers by expert working groups in key areas The new Global Strategy for Women’s, Chil- 7300 women experience a stillbirth. While • Fifteen working papers were developed dren’s and Adolescents’ Health, released important gains have been registered since through online consultation and input from this month (see box), builds on lessons the launch of the 2010 Global Strategy, experts learnt and new evidence and focuses on crit- women, children, and adolescents around • A multistakeholder writing group was ical population groups, such as adolescents the world continue to experience serious vio- constituted and women and children living in fragile and lations of their health and of health related • Consultations took place with member states conflict settings. Its key objectives are to sup- human rights.1 and stakeholders in Geneva, New Delhi, and port the resilience of health systems, to One of the key factors behind the reduc- Johannesburg improve the quality of health services and tion of maternal and child mortality has • Online consultation with public on zero draft ensure equitable coverage, and to work with been improved access to essential interven- of the Global Strategy health enhancing sectors (such as educa- tions and services. Family planning, antena- • New Global Strategy launched at UN General tion, water and sanitation, and nutrition). tal care, delivery at facilities, and skilled Assembly in September 2015 As we start to define the sustainable birth attendance have all increased over the • Operational framework for the new Global development goals and related targets, we past two decades. However, huge inequities Strategy due to be presented at World Health Assembly in May 2016 must increase the momentum in women’s, in coverage and quality continue, and fur- children’s, and adolescents’ health. Equally thermore stronger effort is needed to remove

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barriers to access, which continue to impede communicable and non-communicable dis- outcomes. Low and middle income countries success.2 3 eases (including cancers), and mental can have2: In particular, postpartum care for mothers health—all based on a life course approach. and newborns has not received due attention The targets identified in the sustainable • Up to three times more pregnancies among and remains a missed opportunity in repro- development goals,5 together with the trans- teenage girls in rural and indigenous pop- ductive, maternal, newborn, and child formative agenda envisioned in the new ulations than in urban populations health. Investments in women’s health Global Strategy to ensure that women, chil- • A difference of up to 80% between the beyond reproductive health needs greater dren, and adolescents survive, thrive, and richest and poorest people in the propor- attention, given the rise of effects on health transform, are the impetus to create a para- tion of births attended by skilled health related to non-communicable disease, such digm shift within a generation. personnel as cancer, obesity, and diabetes. This vision necessitates a comprehensive • A gap of at least 18% between the poorest But substantial progress has been made in approach that takes into account the struc- and richest people in the proportion who preventing HIV among neonates, thanks to tural determinants of health, tackles inequi- seek care for children with pneumonia programmes to prevent transmission from ties in access to healthcare, and encourages symptoms, and mother to child. Another success is the accountability. Despite decades of unprece- • A difference of least 25% in antenatal care increase in the prevalence of exclusive breast dented medical advances and innovations in coverage (of at least four visits) between feeding and of oral rehydration therapy, healthcare, the quality of care in general— the most and least educated and between though further effort is needed to increase and of women’s, children’s, and adolescents’ the richest and poorest. coverage. Deaths of children aged under 5 health in particular—is often weak. Building The papers in this supplement highlight years remain high in sub-Saharan Africa and on and extending this unfinished agenda, the three key areas of priorities for the new southern Asia, and many more children’s papers in this collection elaborate the actions Global Strategy: the health needs of adoles- lives could be saved through the equitable needed to improve health and wellbeing of cents, multisectoral response, and emer- scale-up of available, cost effective interven- women, children, and adolescents around the gency situations. tions. A broader and holistic global agenda world. on child health is needed that retains the aim A “grand convergence” is well within our Meeting health needs of adolescents to end preventable deaths among under 5s reach.6 Given political momentum, and with A critical new priority at the heart of the while being able to deal with emerging prior- the existing evidence, we now have the new Global Strategy is the focus on adoles- ities and to achieve sustainable gains among opportunity to end preventable deaths cents. Adolescents aged 10-19 years have school age children. among all women, children, and adoles- specific needs and require a responsive Evidence shows that interventions that are cents, to vastly improve their health, and to health system that takes into account their particularly effective in the areas of repro- bring about the transformative changes biological, emotional, and social develop- ductive, maternal, newborn, and child needed to fully realise their human rights ment. Ensuring their healthy development health are family planning, management of and build resilient and prosperous societies. means making the health system work for labour and delivery, care of preterm births, We know what needs to be done. With a adolescents. But it also requires a focus on breast feeding, and treatment of serious concerted effort we can eliminate wide dis- social risk factors as well as on the factors infectious diseases and acute malnutrition parities in preventable mortality and mor- that can offer a protective effect across vari- The new Global Strategy also needs to bidity. In particular, by improving access to ous health outcomes. This focus includes pay attention to adverse experiences in essential health interventions and building the legal and policy environment. early childhood that can increase the risk resilient health systems, we can achieve the To realise the health and wellbeing of ado- of poor social and health outcomes such as grand convergence within a generation and lescents and protect their human rights, low educational attainment, economic create a world in which no woman, child, or countries need to adopt holistic health poli- dependency, increased violence, crime, adolescent faces a greater risk of preventable cies and education programmes about pre- and substance abuse, poor mental health, death just because of where they live. vention of injuries, violence, and self harm; and a greater risk of adult onset non-com- The new Global Strategy is central to the good sexual and reproductive health out- municable diseases such as obesity, cardio- realisation of this objective. It provides a plat- comes; prevention of non-communicable vascular disease, and diabetes. form for completing the unfinished work of disease; and other crucial aspects of physi- the health related millennium development cal and mental health and development. Paradigm shift goals and to help countries implement the Such education will help adolescents The evidence is clear: investment in child- post-2015 development agenda and the health enhance judgment and learn the skills to birth and delivery can quadruple returns in related sustainable development goals and maximise their health and wellbeing. terms of women’s and newborn’s lives targets. saved and stillbirths and disabilities A multisectoral response reduced.4 The papers in this supplement A vision for the future Another distinguishing feature of the new underline the imperative to accelerate Despite some progress, societies are still fail- Global Strategy is its explicit focus on the momentum and protect the gains made ing women, children, and adolescents, most role of health enhancing and health enabling while also calling for innovative thinking acutely in poor countries and among the sectors. The evidence provided throughout and cutting edge research and approaches poorest communities in all countries. We will this supplement highlights the importance to meet the needs and aspirations of mil- fail in our endeavours if we do not compre- of such interventions in the articulation of a lions of women, children, and adolescents hensively address everyone’s health needs. comprehensive approach to health. around the world. Women, children, and adolescents who are Attention needs to be paid to strengthen- Work on creating a new paradigm for marginalised suffer from various inequities ing health systems’ response. Weak capacity women’s, children’s, and adolescents’ health and discrimination, such as those based on in health systems and the health workforce, will need to be done in a range of areas, such gender, income, age, place of residence, and gaps in infrastructure, and a “verticalised” as sexual and reproductive health and rights, education levels, resulting in worse health focus on biomedical aspects of health

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­interventions hinder the attainment of health human rights to health, wellbeing, and a Strategy, and the authors would like to express their thanks to all of them. goals. Health system resilience, conversely, sustainable future. Contributors and sources: All authors wrote the hinges on institutional capacity and human manuscript, and all have read and agreed to the final capital to adapt and respond to emerging Conclusions version. MT is guarantor. shocks and needs. And policy and Implementation of the new Global Strategy Competing interests: We have read and understood ­operational systems need to ensure continu- depends on effective and independent BMJ’s policy on declaration of interests and have no relevant interests to declare. ing capacity to deliver essential health ser- accountability. However, the reality is very Provenance and peer review: Not commissioned; vices equitably, even during an emergency, different. Several countries still do not have externally peer reviewed. including by building greater self reliance systems of civil registration and vital statis- The authors alone are responsible for the views among communities. tics monitoring or functioning national expressed in this article, which does not necessarily Innovation and financing are central to this health accounts and information systems. represent the views, decisions, or policies of WHO or the institutions with which the authors are affiliated. new vision for women’s, children’s, and ado- To ensure accountability, a minimum stan- Marleen Temmerman, director, Department of lescents’ health. There is an urgent need to dardised reporting system is needed that Reproductive Health and Research, World Health scale up innovations in a sustainable manner. enables comparison of progress across coun- Organization, Geneva Crucially, we also need to transform the tries and regions. Such a system would also Rajat Khosla, human rights adviser, Department of financing landscape, by supporting the value strengthen national capacity and ensure an Reproductive Health and Research, World Health Organization for money agenda; to foster an integrated inclusive process for stakeholders. Further- Zulfiqar A Bhutta, director, Centre for Global Child approach to complete the unfinished agenda more, indicators recommended by the 2011 Health, Hospital for Sick Children, Toronto, Ontario, on child health; and to break down the silos Commission on Information and Account- Canada, and Center of Excellence in Women and Child separating the flows of financing between ability need to be augmented to encompass Health, Aga Khan University, Pakistan women, children, and adolescents. Better the much broader agenda of the 2015 strat- Flavia Bustreo, assistant director general, Family, Women and Child Health Cluster, World Health mechanisms are needed for financing the egy, including human rights. The critical Organisation health of women, children, and ­adolescents role played by UN agencies, academia, and Correspondence to: R Khosla [email protected] who live in conflict or post-conflict settings. consortiums such as Countdown to 2015 in 1 Every Woman Every Child. Saving lives protecting And we need to foster innovative financing the accountability process for millennium futures. 2015. www.everywomaneverychild.org/ global-strategy-2/gs2-progress-report. models at global, regional, and national levels. development goals 4 and 5 must be rec- 2 World Health Organization. State of inequality: ognised.8 In the new Global Strategy we reproductive, maternal, newborn and child health. WHO, Humanitarian crises and emergencies need to further strengthen this process, with 2015. www.who.int/gho/health_equity/report_2015/en. 3 Guttmacher Institute. Adding it up: the costs and Critical new evidence points to the importance an eye on country level accountability and benefits of investing in sexual and reproductive health of paying urgent attention to emergencies. action, and also ensure alignment between 2014. May 2015. https://www.guttmacher.org/pubs/ AddingItUp2014.html. ­Specific vulnerabilities of women, children, global and national levels of accountability 4 Stenberg K, Axelson H, Sheehan P, et al. Advancing and adolescents living in humanitarian crisis and monitoring. social and economic development by investing in settings threaten their health and wellbeing The new Global Strategy gives us a once in women’s and children’s health: a new global investment framework. Lancet 2014;383:1333-54. and the realisation of the Global Strategy. a lifetime opportunity to change the dis- 5 UN Open Working Group of General Assembly on SDGs. Though it is clear that humanitarian crises put course regarding the health of women, chil- Sustainable development goals. 2014. https:// sustainabledevelopment.un.org/content/ women, children, and adolescents at grave dren, and adolescents. It is clear that documents/1579SDGs%20Proposal.pdf. risk, national planning processes often leave business as usual will not work. For women, 6 Global health 2035: a world converging within a generation. Lancet Dec 2013. www.thelancet.com/ humanitarian preparedness, response, and children, and adolescents around the world commissions/global-health-2035. recovery out of their longer term development to survive, thrive, and transform, we need 7 Partnership for Maternal, Newborn & Child Health, UN planning.7 transformative actions that will result in Population Fund, World Health Organization, et al. Abu Dhabi declaration: for every woman every child Increasing investment in women’s, chil- enormous social, demographic, and eco- everywhere. 2015. www.who.int/pmnch/media/ dren’s, and adolescents’ health has many nomic benefits. This is a vision that can unite news/2015/abudhabi_declaration.pdf. 8 Requejo J, Bryce J, Barros A, et al. Countdown to 2015 benefits: it reduces poverty; it stimulates us all: united we stand, divided we fall. and beyond: fulfilling the health agenda for women economic productivity and growth; it creates and children. Lancet 2015;385:466-76. Acknowledgment: Numerous partners from governments, jobs; it is cost effective; and it helps women, UN Agencies, CSOs, and academia have contributed to the children, and adolescents realise their basic development of this supplement and the overall Global Cite this as: BMJ 2015;351:h4414

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Women’s health priorities and interventions Building on the unfinished agenda, Marleen Temmerman and colleagues elaborate actions needed to improve the health and wellbeing of women and girls around the world

ver the past decades, govern- Methods estimated 225 million women have an unmet ments have taken steps towards This paper is based on a desk review and need for modern contraception.14 improving women’s health in synthesis of evidence drawing on global In 2013 almost 60% of all new HIV infec- line with commitments made in epidemiology and health estimates to iden- tions among young people aged 15-24 years key international summits. tify gender differentials in mortality and occurred in girls and young women.15 Tuber- OProgress has been made in reducing mater- morbidity. The interventions are based on culosis is often linked to HIV infection and is nal mortality,1 which accelerated with the syntheses of evidence drawn from evidence among the leading causes of death in women launch of the United Nations secretary reviews previously conducted for WHO ini- of reproductive age (and among women aged ­general’s Global Strategy for Women’s and tiatives.5-7 We used three selection criteria 20-59 years) in low income countries. Nearly Children’s Health in 2010. Use of maternal to identify priority interventions. (1) Inter- 30% of women and adolescent girls are healthcare and family planning has ventions that tackle major causes of mor- affected by anaemia, leading to adverse increased in some countries.2 Progress has bidity and mortality in women and effects on their overall health and wellbeing, also been seen on two determinants of adolescent girls. (2) Interventions that have especially during pregnancy and childbirth. women’s health—school enrolment rates been shown to have a high impact on Sexually transmitted infections, of which for girls and political participation of health and development of women and human papillomavirus infection is the most women—but not for others such as gender adolescent girls. (3) Interventions critical common, disproportionately affect women based violence.3 for the overall health and wellbeing of and adolescent girls. About 70% of cases of However, societies are still failing women women, children, and adolescents (such as cervical cancer worldwide are caused by in relation to health, especially in low interventions related to harmful practices human papillomavirus.16 Untreated syphilis resource settings. Discrimination on the and violation of human rights). We circu- is responsible for about for 212 000 still- basis of their sex leads to health disadvan- lated a draft of the paper for comments births/early fetal deaths and about 92 000 tages for women.4 Structural determinants of through a web based consultation and neonatal deaths every year.17 women’s health, along with legal and policy finalised it according to comments received One in three women aged 15-49 years has restrictions, often restrict women’s access to and expert feedback. experienced physical violence, sexual vio- health services. lence, or both by an intimate partner or This paper elaborates the health prob- Unfinished agenda for women’s health ­sexual violence by a non-partner, with many lems women face, and priority interven- Poor sexual and reproductive health out- short and long term consequences for their tions to overcome them, as a background comes represent a third of the total global health.18 One in four girls and one in seven for and informing the updating of the burden of disease for women aged 15-44 boys experience sexual violence before Global Strategy for Women’s, Children’s years. Unsafe sex and violence are major risk the age of 18.19 and Adolescents’ Health. factors for death and disability among women and girls in low and middle income Emerging priorities for women’s health countries and continue to disproportionately Shifts in population dynamics towards more affect marginalised groups in high income ageing populations, along with an unprece- Key messages countries.8 dented growth in the world’s adolescent Substantial progress has been made in the Although the global maternal mortality population, have led to greater complexities past two decades in improving maternal ratio—the number of maternal deaths per in the global burden of ill health, including health, with a 45% reduction in maternal 100 000 live births—halved between 1990 an increase in non-communicable diseases mortality, but much remains to be done and 2013, this progress is not sufficient to (NCDs).8 In 2012 most premature deaths It is imperative to accelerate the momentum reach the target of millennium development from NCDs among women aged 30-70 years and protect the gains made for women’s goal 5 of a 75% reduction by 2015.9 In 2013 an (82% or 4.7 million) occurred in low and mid- health, as well as to tackle critical gaps and estimated 289 000 women died from compli- dle income countries, with higher rates in acknowledge the lessons learnt cations of pregnancy and childbirth; and 22 women aged 15-59 years than in high income Key health systems interventions million unsafe abortions occurred in 2008 countries.20 are needed to address structural (half all induced abortions in that year), Gender norms and societal structures determinants of women’s health, reduce nearly all in low and middle income coun- mean that the mobility and physical activ- inequities in access, improve quality tries.10 The burden of maternal morbidity, ity of women and girls in some parts of of care, strengthen accountability, and such as obstetric fistulas and uterine pro- the world is often restricted. This can be promote adoption of innovations that lapse, continues to be high.11 Catastrophic further compounded by factors related to improve performance and out of pocket health expenditure for income, household hierarchies, and roles. Priority interventions for women’s health healthcare services, such as treatment of In some regions, this has an adverse effect include providing health information and complications resulting from unsafe abor- on the health and wellbeing of women contraceptive services, strengthening tion, continues to affect women and girls and girls.21 Furthermore, gestational maternal healthcare, tackling non- around the world.12 Each year, 5.4 million ­diabetes affects about 15% of women communicable diseases, and preventing women endure pregnancies that end in worldwide.22 and responding to violence against ­stillbirth (2.6 million in 2009) or neonatal Globally, tobacco use accounts for about women and girls death (2.8 million in 2013).13 Worldwide, an 9% of all deaths due to NCDs in women.

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Maternal smoking is associated with risks in often to the detriment of their own participa- the allocation of resources, such as income, pregnancy, including ectopic pregnancy, tion in the paid workforce. The consequences education, healthcare, and nutrition, are preterm birth, placental problems, miscar- in older age include a greater risk of poverty, strongly associated with poor health, requir- riage, and stillbirth.23 Harmful use of alco- more limited access to good quality health- ing a multisectoral approach integrating the hol, illicit drugs, and other psychoactive care and social care services, and poor contribution of non-health sectors to the substances by girls and women, including health. Several serious medical conditions of overall health and wellbeing of women and during pregnancy, is increasing in many older age, including dementia, are more com- girls. parts of the world. In 2012 an estimated 4% mon in women, yet women find it harder to of deaths of women were attributable solely access the treatment they need. Creating an enabling legal and policy to alcohol use.24 environment Women’s cancers, especially breast and Strengthening health systems and tackling Laws and policies have a direct bearing on cervical cancer, result in high rates of mor- structural determinants of women’s health the realisation of health and human rights tality and morbidity, especially in low and Persistent obstacles in health systems to the by women and girls, including on sexual middle income countries. Widespread major realisation of women’s health and related and reproductive health and rights. inequalities in access to early detection and human rights, including sexual and repro- National and sub-national legal and policy screening lead to large variations in clinical ductive health and rights, include a lack of frameworks should be aligned with rec- outcomes and survival after treatment. gender responsiveness, reflected by a lack of ognised human rights norms and stan- Breast cancer, the leading cause of deaths sex disaggregated data and gender analysis. dards, and countries should establish or from cancer in women (1.7 million new This results in health services not taking strengthen mechanisms to implement cases and 0.5 million deaths in 2012), is into account the specific needs and determi- these standards. diagnosed in low and middle income coun- nants of women’s health or the effect on it of tries mostly at advanced stages, when palli- gender inequality. Removing these obsta- Reducing inequalities ative care is the only option.25 Cervical cles requires targeted innovations that Another key focus in tackling the remaining cancer is the fourth most common cancer tackle structural inequalities and improve gaps should be the persistent inequalities affecting women worldwide. In low and the quality, coverage, and completeness and inequities in the accessibility and middle income countries, it is the third lead- of health services for women. Box 1 sum- ­quality of health systems across and within ing cause of death from cancer in women, marises health systems interventions for countries.28 In many settings, health and in most cases women have limited women’s health. ­systems continue to have limited accessi- access to screening and treatment of pre- bility for certain populations, such as for cancerous lesions, with resultant late stage Structural determinants of women’s poor people, older people, adolescents, rural identification.26 health residents, and residents of urban slums, and Mental disorders constitute another criti- Sex based biological factors interact with for uninsured or undocumented people,29 as cal emerging health problem for women and inequalities based on gender, age, income, well as limited capacity as measured by indi- girls. Suicide is a leading cause of death in race, disability, ethnicity, class, and envi- cators such as health worker density, cover- adolescent girls and in women aged 20-59 ronmental factors among others in shaping age of critical services, use of health years globally.27 Women experience more women’s exposure to health risks, experi- information systems, availability of essential depression and anxiety than men.28 Patterns­ ence of ill health, access to health services, medicines and supplies, and quality­ assur- of mental health problems differ between and health outcomes. Gender inequalities in ance.29 men and women as a result of different gen- der roles and responsibilities, biological dif- Box 1 Health systems interventions for women’s health ferences, and variations in social contexts.27 • Universal health coverage for key health interventions for women Women who have been exposed to violence • Inequities in access by intimate partners are twice as likely to ––Steps to enhance coverage (physical, social, geographic, linguistic, financial) have depression and alcohol use disorders ––Removal of barriers to access, including legal and policy barriers, criminalisation, third party and four times more likely to commit suicide, authorisation, and overly broad conscientious objection compared with women not exposed to this • Quality of care, including supplies violence.18 Mental health services are often ––Quality assurance of service delivery, update of evidence based norms, standards, and policies limited in lower income countries, and ––Adequate supplies for key women’s health problems women benefit even less from these services ––Respectful care standards and cultural sensitivity than do men.27 • Health workforce Chronic obstructive pulmonary disease is ––Development and distribution of health workforce for women’s health problems, including also a leading cause of disease and death midwives among older women. In low income coun- ––Pre-service and in-service training tries, the primary risk factor for women’s ill ––Provision of incentives to enhance quality, retention, etc. health is exposure to indoor air pollution • Monitoring and accountability caused by the burning of solid fuels for ––Investing in strengthening the overall governance of the health system to ensure better heating and cooking. However, health accountability for results and for realisation of rights ­systems are not ­adequately equipped to ––Strengthening management capacity at national and sub-national levels ­provide prevention and treatment of these • Adoption and institutionalisation of innovations that enhance quality, coverage, efficiency, and/or conditions. completeness of health interventions to women Globally, women represent a higher pro- ––Client specific innovations that improve access and reduce barriers, including the use of digital portion of older adults. Traditionally, women technologies have provided most of the care in the family, ––Health system innovations that improve performance and drive measurement and accountability, looking after both children and older people, including digital innovations for vital events

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Quality of care Health emphasised multiple dimensions of and youths, in and out of school, as well as Women’s health services, particularly sexual accountability, by adopting a framework to adult women. CSE provides thorough, sci- and reproductive health services, are often built on three pillars: monitoring, review, entifically accurate, non-judgmental infor- not provided at a level of quality that meets and action (including redress).34 The inde- mation and assists people to develop skills human rights standards.30 The persistence pendent Expert Review Group, established for decision making, critical thinking, com- of poor sexual and reproductive health out- to monitor and assess progress in imple- munication, and negotiation of interper- comes despite availability of supplies and mentation of recommendations made by sonal relationships. Quality CSE facilities underscores the need to strengthen the commission, has stated that account- programmes cover human rights, gender the quality of health systems.31 According to ability needs to be based on certain core equality, respectful relationships, human the recent WHO multi-country survey on principles: clarity about stakeholders’ sexuality, and sexual and reproductive maternal and newborn health, even when responsibility for action; accurate mea- health and rights. Effective CSE programmes the coverage of effective interventions is high surement; independent verification; impar- seek to roll out nationwide curriculums and (above 80%) many women still die or experi- tial, transparent, and participatory review; teacher training materials based on interac- ence severe morbidity from haemorrhage, and clear recommendations for future tive methodologies; they select and super- hypertensive and other disorders of preg- action.34 vise teachers and facilitators; and they work nancy, and prolonged obstructed labour Accountability is also intrinsic to ensuring with parents, school principals, and pro- (often resulting in death, stillbirth, or obstet- that individuals’ agency and choice are gramme managers, among others, at com- ric fistulas).32 respected, protected, and fulfilled. Agency munity level and through meaningful Quality of care must therefore go side by and choice are fundamental to enabling peo- participation of adolescents.35 Specific atten- side with the increase of service coverage, ple to have a voice and to hold governments tion needs to be paid to adolescent girls in as this alone does not guarantee the health and all relevant stakeholders to account. the context of CSE programmes. results.32 33 Strengthening health networks, Promotion and protection of the interna- transportation, and referral systems is still tional development agenda requires placing Contraceptive information and services an unfinished agenda in many countries. the human rights and health of women and for all who need them Upgrading of first and second level facilities adolescent girls, particularly sexual and Information on contraception and inte- with appropriate infrastructure and equip- reproductive health and rights, at its centre. grated comprehensive sexual and repro- ment, and providing adequate numbers of Participatory monitoring and accountability ductive health services are vital means for skilled and motivated health workers, with mechanisms that meaningfully engage women and girls to maintain health, and ongoing training and mentoring for wom- women at the sub-national, national, and their availability is necessary for women en’s health, including on sexual and repro- global levels are a critical part of this. and girls to enjoy their human rights. Con- ductive health and abortion care, and on traception has clear health benefits. For tackling violence against women, is neces- Priority interventions for women’s health example, prevention of unintended preg- sary to increase coverage and facilitate On the basis of the existing evidence and nancies results in a subsequent decrease access. reviews conducted,5-7 we propose several pri- in maternal and infant mortality and Quality of care is a multidimensional con- ority interventions. Box 2 gives a synthesis of ­morbidity. Providing access for all women cept that is affected by stakeholders’ priori- these interventions, which are not in an in developing countries who have an ties and context.33 Attributes of quality of order of priority. unmet need for modern methods of contra- care include access to care, effectiveness of ception would prevent 54 million unin- care, safety, equitability, communication, Providing health information and tended pregnancies, 26 million abortions acceptability, efficiency, and privacy and comprehensive sexuality education (of which 16 million would be unsafe), and confidentiality.33 Evidence based health information and com- 7 million miscarriages; this would also pre- prehensive sexuality education (CSE) is a key vent 79 000 maternal deaths and 1.1 mil- Enhancing accountability intervention for promotion and protection of lion infant deaths. This situation would The Commission on Information and women’s health. Such education and infor- particularly benefit adolescent girls, who Accountability for Women’s and Children’s mation should be available to all ­adolescents are at increased risk for medical complica- tions associated with pregnancy and who Box 2 Summary of priority health interventions and health system enablers for are often forced to make compromises women’s health in education and employment that may • Health information and comprehensive sexuality education lead to poverty and lower educational • Comprehensive and integrated package of sexual and reproductive health services, including family attainment.36 planning Effective policies at the national and local • Prevention of unsafe abortion; provision of safe abortion and post-abortion care levels should ensure availability of a mix of • Pregnancy care accessible, acceptable, and high quality • Management of pregnancy complications and maternal morbidities modern contraceptive methods, including • Counselling and birth preparedness emergency contraception, to meet women’s • Skilled care at birth; comprehensive emergency obstetric and newborn care needs across the life course; these should be • Prevention of and response to violence against women and harmful traditional practices evidence based and free from bias, discrimi- • Cervical and breast cancer screening and treatment nation, and unnecessary medical eligibility • Testing and treatment for HIV, sexually transmitted infections, and tuberculosis according to need criteria. Financing for family planning • Promotion of healthy behaviours for preventing non-communicable diseases (for example, tobacco, should be strengthened through costed alcohol, obesity) implementation plans, health finance facili- • Human papillomavirus vaccine ties, and national ­budgets. Providers should • Adequate nutrition be trained and supervised to meet human • Mental health and psychosocial support rights standards for quality care.

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Strengthening maternal healthcare young and marginalised people, including aggressive marketing of tobacco products As maternal and child mortality continues to young women and girls and higher risk through accelerated and effective implemen- decrease sharply in many countries, to make populations, to information and services tation of the Framework Convention on more progress, priority attention is needed to on the risks and symptoms of STIs and HIV Tobacco Control; inter-sectoral collaboration ensure the quality of maternal healthcare. and to the skills and means to protect to identify and promote actions outside Functioning health systems will include themselves; provide universal access to health systems in relation to NCDs; greater emergency obstetric and newborn care and antiretroviral drugs; ensure privacy and involvement of women and girls in identify- strong capacity at the secondary level to confidentiality; invest in development of ing problems and solutions and implement- treat complications of childbirth, with effec- inexpensive ­technologies for diagnosis, ing policies in the fight against NCDs; tive referral from the community and pri- treatment, and vaccines;­ strengthen STI integration of sex and gender in the design, mary levels.37 38 Further strengthening of surveillance, including of microbial resis- analysis, and interpretation of studies on health services delivery systems is also tance; and challenge prevailing gender and NCDs by research institutions; and innova- needed, taking into account task shifting sexuality norms. tive partnerships to improve access to afford- and innovative approaches such as mhealth able, high quality, essential medicines to and ehealth. Preventing and responding to violence treat NCDs.42 against women and girls Strengthening the health workforce Challenging social norms and gender Tackling women’s cancers Attention is needed to educate, deploy, inequalities is a critical element in pre- “Changing reproductive health needs over retain, and improve the quality of the cadres venting and responding to all forms of vio- the life cycle” includes the prevention, of primary healthcare workers, such as mid- lence against women and girls. This diagnosis, and treatment of reproductive wives and nurses, through quality educa- requires multi-sector programmes and system cancers. The human papillomavirus tion, effective regulation, and an enabling strategies that address structural determi- vaccine makes widespread primary preven- work environment that includes effective nants, including gender equality and the tion, as well as screening and treatment of referral.39 Healthcare workers should be empowerment of women. Laws, policies, precancerous lesions, potentially feasible empowered and provided with the necessary protocols, and guidelines are needed for in countries with weak health systems. knowledge, skills, medicines, and equip- all sectors, emphasising that violence Advances for breast cancer are primarily in ment. Furthermore, health workers should against women and girls is a violation of treatment and identification, which can be be provided with training and capacity human rights, imposes enormous health used for risk screening and need to be fur- building to sensitise them to approach the burdens on individuals, families, and soci- ther available for all. Important new work is health needs of women and adolescent girls ety, and will not be tolerated. The health being done in low income countries to in a more responsive manner. system has an important role in the pre- inform women, and to train community and vention of and response to violence against primary healthcare workers to support Providing safe abortion and post-abortion women and girls by ensuring access to them, to seek diagnosis and care early care timely, effective, and affordable health ser- enough for curable cases to be treated and Unsafe abortion, one of the leading causes vices for women and girls who are victims to improve the management of greatly over- of maternal death and injuries, is entirely of violence, particularly sexual and repro- burdened treatment facilities. This work preventable because technologies and safe ductive health services. Sexual and repro- needs to be strengthened. procedures are well known, cost little, and ductive health, adolescent health, and should be widely available. WHO’s technical maternal health services offer unique Adequate nutrition and policy guidelines for access to safe abor- entry points to identifying violence and Iron deficiency anaemia increases the risk tion should be implemented.40 Laws providing the necessary support and care of haemorrhage and sepsis during child- restricting access to safe abortion do not to women and girls exposed to violence, birth. It causes cognitive and physical defi- reduce or end recourse to abortion, and including mental health, emergency con- cits in young children and reduces abortion related mortality is higher in coun- traception, safe abortion, and STI and HIV productivity in adults. Women and girls are tries with restrictive laws. The UN Special prophylaxis for post-rape care, in line with most vulnerable to anaemia owing to insuf- Rapporteur on the Right to Health has found WHO’s clinical and policy guidelines. This ficient iron in their diets, menstrual blood that criminalising reproductive behaviours, requires providers to be adequately trained loss, and periods of rapid growth. In some including abortion, is a violation of human and supported. regions, women and girls are denied access rights and contributes to poor health out- to nutrition owing to cultural factors and comes.41 Although access to post-abortion Tackling non-communicable diseases societal norms. This severely affects the care for treatment of the complications of As detailed above, women are increasingly overall health and wellbeing of women and unsafe abortion has increased, women in facing a disproportionate burden of NCDs. girls, especially during pregnancy, and many countries still do not have access to Prevention requires interventions to promote leads to severe birth outcomes and health this life saving care or are mistreated when healthy behaviours and reduce risk factors conditions. This requires cross sectoral col- they seek it. for NCDs, and governments need to take laboration to ensure provision of adequate steps to overcome economic, socio-cultural nutrition to women and girls. For example, Preventing and treating sexually health inequalities and geographic barriers. the paper by Branca and colleagues transmitted infections and HIV in women Providing women with clean cooking and ­recommends that interventions to reduce To effectively end the AIDS epidemic by heating devices reduces their risk for several iron deficiency anaemia need to be rolled 2030 and reduce the burden of other NCDs while also protecting the health of out at a larger scale, achieving universal ­sexually transmitted infections (STIs), infants and young children. Interventions coverage.43 This also requires interventions ­governments and the international com- include integration­ of prevention and con- to ensure gender equality and promotion of munity should fully implement effective trol of NCDs into existing health systems ini- women’s empowerment to ensure women’s prevention interventions; ensure access for tiatives; protection of women and girls from

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full access to and control over resources online consultations for their comments on the draft 13 Save the Children. Surviving the first day: state of the and social protection. manuscript. world’s mothers. Save the Children, 2013. Contributors and sources: The Women and 14 Singh S, Darroch JE, Ashford LS. Adding it up: the costs and benefits of investing in sexual and reproductive Health Working Group for the Global Strategy for Mental health health, 2014. Guttmacher Institute, 2015. Women’s, Children’s and Adolescents’ Health 15 Joint United Nations Programme on HIV/AIDS. Global Gender is a critical determinant of mental devised the article. MT, RK, and LS wrote the first draft. report: UNAIDS report on the global AIDS epidemic. health and mental illness. The morbidity Working group members LL and ZM contributed to UNAIDS, 2012. subsequent drafts. RK ensured that relevant feedback 16 World Health Organization. Global incidence and associated with mental illness has received from the consultations for the UN secretary general’s prevalence of selected curable sexually transmitted substantially more attention than the gen- Global Strategy for Women’s, Children’s and infections—2008. WHO, 2012. der specific determinants and mechanisms Adolescents’ Health, and the online consultation, was 17 World Health Organization. Sexually transmitted incorporated into the draft. All authors have read and infections. Factsheet 110. 2013. www.who.int/ that promote and protect mental health and agreed to the final version. MT is the guarantor. mediacentre/factsheets/fs110/en/. foster resilience to stress and adversity. Competing interests: We have read and understood 18 World Health Organization, London School of Hygiene and Tropical Medicine, South African Medical Research BMJ policy on declaration of interests and have no Gender differences occur particularly in the Council. Global and regional estimates of violence relevant interests to declare. rates of common mental disorders such as against women: prevalence and health effects of depression, anxiety, and somatic com- Provenance and peer review: Not commissioned; intimate partner violence and non-partner sexual externally peer reviewed. violence. WHO, 2013. plaints. These disorders affect approxi- The authors alone are responsible for the views 19 Centers for Disease Control and Prevention. Sexual mately one in three people in the expressed in this article, which does not necessarily violence: facts at a glance. 2012. www.cdc.gov/ violenceprevention/pdf/sv-datasheet-a.pdf. represent the views, decisions, or policies of WHO or community (with a female predominance), 20 AbouZahr C. Trends and projections in mortality the institutions with which the authors are affiliated. are closely associated with intimate partner and morbidity. Paper prepared for the ICPD Beyond 1 violence, and constitute a serious public Marleen Temmerman director 2014 Expert Meeting on Women’s Health—rights, Rajat Khosla human rights adviser1 empowerment and social determinants, Mexico City, health problem. Reducing gender dispari- 2013. 2 ties in mental health requires action at Laura Laski chief 21 World Health Organization. Update on the WHO Zoe Mathews professor of global health and social Commission on Ending Childhood Obesity. 2014. many levels. In particular, national mental statistics3 http://apps.who.int/gb/ebwha/pdf_files/EB136/ B136_10-en.pdf. health policies must be developed on the Lale Say senior adviser1 22 International Diabetes Federation. Policy briefing. basis of an explicit analysis of gender dis- 1Department of Reproductive Health and Research, Diabetes in pregnancy: protecting maternal health. IDF, parities in risk and outcome. This further World Health Organization, Geneva 1211, Switzerland 2011 (available at www.idf.org/publications/ requires investments in gender sensitive 2Sexual and Reproductive Health Branch, Technical diabetes-pregnancy-protecting-maternal-health). Division, United Nations Population Fund, New York, 23 World Health Organization. WHO global report on treatment approaches and services to be mortality attributable to tobacco. WHO, 2012. USA developed at the national level.44 For 24 Nelson D, Jarman DW, Rehm J et al. Alcohol-attributable 3University of Southampton, Southampton, UK women to be able to access treatment at all cancer deaths and years of potential life lost in the US. On behalf of the Women and Health Working Group for Am J Public Health 2013;103:641-8. levels from primary to specialist care and the Global Strategy for Women’s, Children’s and 25 World Health Organization. Breast cancer: prevention inpatient as well as outpatient facilities, Adolescents’ Health. and control. 2011. www.who.int/cancer/detection/ breastcancer/en/. services must be tailored to meet their Correspondence to: R Khosla [email protected] 26 World Health Organization. Human papillomavirus needs.44 Women must therefore have access 1 Say L, Chou D, Gemmill A, et al. Global causes of (HPV) and cervical cancer. Factsheet 380. 2013. www. maternal death: a WHO systematic analysis. Lancet who.int/mediacentre/factsheets/fs380/en/. to meaningful assistance to seek treatment, Glob Health 2014;2:e323-33. 27 De los Angeles CP, Lewis WW, et al. Use of mental health and the full range of women’s psychosocial 2 United Nations Inter-agency Group for Child Mortality services by women in low and middle income countries. and mental health needs must be Estimation. Levels and trends in child mortality. United Journal of Public Mental Health 2014;13:4. Nations Children’s Fund, 2014 (available at www.who. 28 United Nations Secretary-General. Summary report on addressed. This, according to WHO, int/maternal_child_adolescent/documents/ the assessment of the status of implementation of the involves services adopting a life course levels_trends_child_mortality_2014/en/). Programme of Action of the International Conference 3 World Health Organization. Women and health: 20 on Population and Development. United Nations, 2014 approach, by acknowledging current and years of the Beijing declaration and platform for action. (available at http://icpdbeyond2014.org/uploads/ past gender specific exposures to stressors 2015. http://apps.who.int/gb/ebwha/pdf_files/EB136/­ browser/files/sg_report_on_icpd_operational_ and risks and by responding sensitively to B136_18-en.pdf. review_final.unedited.pdf). 4 World Health Organization. Women and health: today’s 29 Say L, Raine R. A systematic review of inequalities in the life circumstances­ and ongoing gender evidence tomorrow’s agenda. WHO, 2009. use of maternal health care in developing countries: based roles and responsibilities.44 5 World Health Organization, Partnership for Maternal, examining the scale of the problem and the importance Newborn and Child Health, Aga Khan University. of context. Bull World Health Organ 2007;85:812-9. Essential interventions, commodities and guidelines 30 Germain A. Meeting human rights norms for the quality Conclusion for reproductive, maternal, newborn and child health of sexual and reproductive health information and (RMNCH). PMNCH, 2011. services: discussion paper. ICPD beyond 2014. Despite progress, persisting and emerging 6 Stenderg K, Axelson H, Sheehan P, et al. Advancing International Conference on Human Rights. 2013. problems challenge women’s health. social and economic development by investing in 31 Independent Expert Review Group (iERG). Every woman, Responding to these requires a compre- women’s and children’s health: a new global every child: strengthening equity and dignity through investment framework. Lancet 2014;383:1333-54. health. The second report of the independent Expert hensive approach including implementa- 7 World Health Organization. Strategies toward ending Review Group (iERG) in information and accountability tion of effective interventions at both preventable maternal mortality. 2015. www.who.int/ for women’s and children’s health. WHO, 2013. reproductivehealth/topics/maternal_perinatal/epmm/ 32 Souza JP, Gulmezoglu AM, Vogel J, et al. Moving clinical and health systems level. Addi- en/. beyond essential interventions for reduction of tionally, environmental, social, economic, 8 World Health Organization. Global health estimates maternal mortality (the WHO Multi-country Survey and political determinants that result 2000-2012. WHO, 2014. on Maternal and Newborn Health): a cross-sectional 9 World Health Organization (WHO), United Nations study. Lancet 2013;381:1747-55. in unequal access to care should be tack- Children’s Fund (UNICEF), United Nations Population 33 Bruce J. Fundamental elements of the quality of care: led to ensure the ending of preventable Fund (UNFPA), World Bank. Trends in maternal a simple framework. Stud Fam Plan 1990;21:61-91. mortality: 1990-2013. WHO, UNICEF, UNFPA and The 34 Commission on Information and Accountability for deaths, morbidities, and disabilities World Bank estimates. WHO, 2014. Women’s and Children’s Health. Keeping promises, among women and improve their health. A 10 World Health Organization. Unsafe abortion: global measuring results. WHO, 2011 (available at www.who. and regional estimates of the incidence of unsafe int/topics/millennium_development_goals/ focus on inequalities and on marginalised abortion and associated mortality in 2008. 6th ed. accountability_commission/Commission_Report_ groups, including in humanitarian set- WHO, 2011. advance_copy.pdf). tings, will help in achieving convergence 11 Firoz T, Chou D, von Dadelszen P, et al. Measuring 35 Haberland N, Rogow D. Sexuality education: emerging maternal health: focus on maternal morbidity. Bull trends in evidence and practice. J Adolesc Health between high and low income countries World Health Organ 2013;91:794-6. 2015;56(1):S15-21. within a generation. 12 World Health Organization. Designing health financing 36 World Health Organization. WHO guidelines on systems to reduce catastrophic health expenditure. preventing early pregnancy and poor reproductive Acknowledgment: We thank Ann Stars, Claudia Garcia WHO, 2005 (available at www.who.int/health_ outcomes among adolescents in developing Moreno, Maria Jose Alcala and all the contributors to the financing/pb_2.pdf). countries. WHO, 2011.

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37 World Health Organization. Working with individuals, 40 World Health Organization. Safe abortion: technical and 43 Branca F, McLean E, Piwoz E, et al. Nutrition and health families and communities to improve maternal and policy guidance for health systems. WHO, 2012:90-1. in women, children, and adolescent girls. BMJ 2015;351: newborn health. WHO, 2010. 41 UN General Assembly. Interim report of the Special h4173. 38 Murray SF, Pearson SC. Maternity referral systems Rapporteur on the right of everyone to the enjoyment 44 World Health Organization, Department of Mental in developing countries: current knowledge and of the highest attainable standard of physical and Health and Substance Dependence. Gender disparities future research needs. Soc Sci Med 2006;62: mental health. A/66/254. 2011. www.ohchr.org/EN/ in mental health. 2009. www.who.int/mental_health/ 2205-15. HRBodies/SP/Pages/GA66session.aspx. media/en/242.pdf?ua=1. 39 Van Lerberghe W, Matthews Z, Achadi E, et al. Country 42 NCD Alliance. Non-communicable diseases: a priority experience with strengthening of health systems and for women’s health and development. 2011. www. Cite this as: BMJ 2015;351:h4147 deployment of midwives in countries with high who.int/pmnch/topics/maternal/2011_women_ncd_ maternal mortality. Lancet 2014;384:1215-25. report.pdf.pdf.

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Children’s health priorities and interventions Wilson Were and colleagues explain why the global community should continue to invest in children’s health, to complete the unfinished child survival agenda and tackle the emerging child health priorities

lobally, deaths in children aged Health and the sustainable development under 5s that occurs within the first month of under 5 years declined by approx- goals agenda. life increased from 37% in 1990 to 44% in imately 50% from 12.7 million in 2013.1 Deaths in under 5s are increasingly 1990 to 6.3 million in 2013, but Methods concentrated in sub-Saharan Africa and progress has been insufficient to This paper is based on the forecasted southern Asia, and more than 50% occur in Gachieve the millennium development goal 4 changes in the distribution of causes of settings affected by conflict, displacement, target of a two thirds reduction by 2015.1 The death in under 5s as countries move towards and natural disasters. Sub-Saharan Africa good news is that many countries have been an absolute target of 25 or fewer deaths per has the highest under 5 mortality rate of 92 able to accelerate the decline in under 5 mor- 1000 live births by 2030. We estimated deaths per 1000 live births—more than 15 tality in the past two decades, more so follow- changes in the profile of the causes of death times the average for developed regions. ing the launch of the United Nations secretary by examining the current distribution of Deaths are unevenly distributed between general’s Global Strategy for Women’s and causes of death in countries with different and within countries. Children’s Health in 2010.2 However, 17 000 levels of under 5 mortality (table 1 ). Data on children under 5 still die every day, largely levels and causes of mortality by country Epidemiological transition in under 5 from preventable communicable diseases came from WHO’s Global Health Observa- mortality and malnutrition; among those who survive, tory.5 This predicted epidemiological profile As under 5 mortality declines, countries will an estimated 200 million children are unable served as a basis to identify emerging priori- face an epidemiological transition marked by to attain their full developmental potential.3 4 ties. We drew priority interventions from the a shift in the relative contribution of communi- At the same time, congenital anomalies, evidence syntheses previously conducted by cable and non-communicable diseases as non-communicable diseases, and injuries WHO and partners.6 7 Priority interventions major causes of childhood morbidity and mor- are becoming increasingly important causes identified are those that tackle major causes tality.11 In the next two decades, these changes of morbidity and mortality in childhood.5 As of newborn and child mortality, as well as are likely to occur in the 68 countries where a consequence, the decades ahead will be child development, and have been shown to current under 5 mortality is at least 35/1000 marked by this dual burden of childhood dis- have a high impact or are beneficial for the live births. As a result, most countries will see eases, affecting most countries. emerging priorities. a steady increase in the relative importance of Here, we define children as aged 0-10 We drew strategic directions from the con- deaths due to congenital anomalies, non-com- years. We present evidence based essential cept of universal health coverage, whereby all municable diseases, and injuries. interventions to end preventable child people should be able to equitably receive the Figure 2 illustrates the epidemiological deaths and promote healthy growth and full spectrum of essential, high quality health transition of the causes of death as the development6; and we provide strategic services—including health promotion, pre- under 5 mortality rate declines from 55 per directions in support of the new Global Strat- vention, and treatment; rehabilitation; and 1000 live births to 50, 20, and less than 5 per egy for Women’s, Children’s and Adolescents’ palliative care—without suffering financial 1000 live births.5 The relative contribution hardship.8 The paper also draws on the com- of congenital anomalies, non-communica- Key messages ments and feedback provided during the ble diseases, and injuries together is likely expert and public consultation on the back- to increase from 12% to 14%, 34%, and 52%, The millennium development goals were ground paper on children’s health priorities respectively, of all deaths in under 5s. instrumental in increasing investment and prepared for the new Global Strategy for Wom- Meanwhile, the relative contribution of action for child survival, thus reducing en’s, Children’s and Adolescents’ Health.9 infectious diseases is likely to decline from under 5 mortality by approximately 50% 53% to 40%, 24%, and 8%, respectively. For over the past two decades The unfinished agenda for children’s health example, in Bangladesh, the under 5 mor- Despite the gains made, 17 000 children Of the estimated 6.3 million children aged tality declined from 144/1000 live births in under 5 years of age still die every day, under 5 years who died in 2013, more than mostly in sub-Saharan Africa and southern 70% died in the first year of life.5 The leading Asia and in countries affected by conflict causes of mortality were preventable new- Table 1 | Distribution of countries and number and natural disasters born problems and infectious diseases—that of deaths in under 5s according to levels of 5 The future demands attention not only is, preterm birth complications (15%), intra- mortality, 2013 to the unfinished child survival agenda partum related complications (11%), pneu- Under 5 mortality No (%) of rate (per 1000 live countries No (%) of deaths but also to a more holistic global child monia (15%), diarrhoea (9%), and malaria health agenda recognising the emerging births) (n=194) (n=6 282 286) (7%). In addition, 45% of all deaths in under priorities <5 33 (17) 26 273 (0.4) 5s were associated with undernutrition, and 5-15 51 (26) 425 262 (6.8) Strategic choices have to be made to move more than 80% of newborn deaths were 15-25 29 (15) 199 529 (3.2) from “business as usual” to innovative, associated with low birth weight (fig 1 ).10 25-35 13 (7) 329 956 (5.3) multiple, and tailored delivery approaches The reduction in neonatal mortality has 35-45 11 (6) 251 570 (4.0) to increase access, coverage, and quality been slower than that for older children; as a 45-55 12 (6) 1 580 486 (25.2) of child health services consequence, the proportion of deaths in >55 45 (23) 3 469 210 (55.2)

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and sanitation, and a safe environment are Meningitis (%) Neonatal all essential to protect and support chil- Pertussis ( %) Tetanus Diarrhoea dren’s health and prevent common condi- HIV/AIDS Pneumonia (%) ( %) tions such as pneumonia and diarrhoea.21 22 (%) Neonatal Complications Other from preterm Measles ‚% birth (%) Congenital % Strategic directions „% Congenital €€% Pneumonia ‚ƒ% Delivery of comprehensive child health ser- anomalies/ ‡% ƒ% NCDs vices requires functional health systems and †% ƒ% Other €% strategies tailored to national and subna- group ‡% †% Sepsis/ tional epidemiological situations. Major bot- conditions ƒ% meningitis Intrapartum tlenecks to universal health coverage include Malaria related limited access to and poor quality of health Injury Diarrhoea services, suboptimal programme manage- Fig 1 | Global causes newborn and under 5 mortality.5 10 NCD=non-communicable disease ment, poor procurements and supply chain management systems, inadequately pre- pared and supported health workforce with Pneumonia Birth asphyxia/trauma largely absent from global child survival ini- provider shortages, and failure to convert Diarrhoeal diseases Congenital anomalies tiatives.13 In 2012 violence and unintentional national policies into action plans.23 As a Neonatal severe infections Injuries injuries killed an estimated 740 000 children consequence, the coverage of many essential Other infections Other NCDs Prematurity Other (group I) under the age of 15, with the latter account- interventions remains low (table 2), a chal- 5  ing for 90% of these deaths. Similarly, the lenge that must be overcome as part of the worldwide number of overweight children sustainable development agenda.  increased from an estimated 32 million in Health sector and multisectoral efforts are 2000 to 42 million in 2013, including in coun- needed to overcome this low coverage of  tries with a high prevalence of childhood interventions, the inequalities, and the undernutrition.5 14 If these trends continue, social determinants of health. We propose  by 2025 the prevalence of overweight in chil- five strategic directions to improve the cur-  dren under 5 years of age will rise to an esti- rent situation and move from “business as mated 11% from 7% worldwide. usual” to innovative, multiple, and tailored  delivery approaches to increase access, cov- Cause specific proportional mortality > ≤ >- Priority interventions erage, and quality of child health services. >- >- >- >- Box 1 summarises evidence based essential Under 5 mortality rate (per 1000 live births) interventions for child survival, growth, and Delivery platforms Fig 2 | Distribution of causes of death in development that are well known but yet not Service delivery ought to ensure availability children under 5 according to levels of under 5 reaching all children who need them.6 15 16 of and seamless access to integrated pack- 5 mortality rate. NCD=non-communicable They include health and non-health sector ages of interventions through an optimal disease interventions that need to be implemented at mixture of community (including home) and scale and with quality to close the equity gap facility (health centre and hospital) based 1990 to 88/1000 live births in 2000 and to and reach universal coverage. care. Optimising the mixture of community 41/1000 live births in 2013, at an annual rate Box 2 summarises beneficial interventions and facility based delivery of services is a of reduction of 5.4%. In the period 2000-13, for tackling emerging priority conditions in widely used strategy to ensure that interven- the relative contribution of diarrhoea childhood. They include clinical and tions reach populations, when and where decreased from 13% to 6%, that of measles non-clinical interventions and supportive they need them.24 Evidence has shown that from 4% to 1%, and that of pneumonia from laws and policies. Prevention of injuries, community health workers can increase 18% to 14%. overweight, and obesity, for example, access to preventive interventions such as depend on appropriate national policies as health education, breast feeding and nutri- Emerging priorities for children’s health well as services.17 18 The Commission on tion promotion and support, essential new- Congenital anomalies, injuries, and Ending Childhood Obesity recommended a born care, stimulation and psychosocial non-communicable diseases (chronic respi- multifaceted approach19 : interventions that support, and use of insecticide treated nets.25 ratory diseases, acquired heart diseases, tackle maternal health, infant and young Similarly, appropriately trained and sup- childhood cancers, diabetes, and obesity) child feeding practices, marketing of ported community health workers can pro- are the emerging priorities in the global child unhealthy foods, and factors that restrict vide treatment interventions for pneumonia, health agenda. Congenital anomalies affect physical activity.18 Similarly preconception diarrhoea, malaria, and severe acute malnu- an estimated 1 in 33 infants, resulting in 3.2 and periconception care interventions are trition.26 However, for community health ser- million children with disabilities related to increasingly important, not only to prevent vices to function optimally, they need to be birth defects every year.10 The global disease congenital anomalies and optimise fetal part of the health system, and country spe- burden due to non-communicable diseases development but also to enhance health cific strategies need to be in place to deter- affecting children in childhood and later in during the child’s life.20 mine where and how to deliver these services. life is rapidly increasing, even though many Multisectoral interventions are critical to In India, training of community health work- of the risk factors can be prevented.12 tackle social determinants of health and ers to conduct postnatal home visits, training Injuries (road traffic injuries, drowning, child health outcomes. Alleviation of pov- of physicians and nurses to treat or refer sick burns, and falls) rank among the top three erty, education and empowerment of children, and strengthening of drugs and causes of death and lifelong disability women, laws and policies on marketing of supervision resulted in substantial improve- among children aged 5-15 years, yet they are food products, access to safe drinking water ments in neonatal and infant survival.27

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Box 1: Summary of essential newborn and childhood health interventions with strong demand creation and commu- nity buy-in. Adolescence and pre-pregnancy The Global Action Plan for the Prevention • Family planning and Control of Pneumonia and Diarrhoea • Preconception care* (GAPPD) is another form of integration.22 It Pregnancy provides a framework for coordinated and • Appropriate care for normal and high risk pregnancies integrated actions to improve feeding and Childbirth nutrition of infants and young children, • Promotion and provision of thermal care for all newborns access to safe drinking water and sanitation, • Promotion and provision of hygienic cord and skin care hand washing with soap, reduction in indoor • Promotion and support for early initiation and exclusive breast feeding within the first hour air pollution, immunisation, prevention of • Newborn resuscitation HIV, and treatment of pneumonia and diar- rhoea. GAPPD is being implemented in sev- Postnatal period eral countries, and plans are under way to • Antibiotics for newborns at risk and for treatment of bacterial infections evaluate the extent to which it has been • Appropriate postnatal visits implemented. For example, Ghana, among • Extra care for small and sick babies (kangaroo mother care, treatment of infection, support for feeding, other countries, introduced pneumococcal and management of respiratory complications) conjugate and rotavirus vaccines into rou- Infancy and childhood tine immunisation and adapted the “Pocket • Exclusive breast feeding for six months and continued breast feeding up to at least two years with book of hospital care for children.” appropriate complementary feeding from six months Although integration of services is most • Monitoring and care for child growth and development efficient, vertical programmes may be desir- • Routine immunisation for common childhood diseases, including introduction of new vaccines able as a temporary measure where the against Haemophilus influenzae, Pneumococcus, and rotavirus health system is weak but a rapid response is • Micronutrient supplementation, including vitamin A from 6 months needed to target vulnerable populations.31 • Prevention and management of childhood malaria This was the case in tackling the HIV epi- • Prevention and management of childhood pneumonia demic, for which an urgent response was • Prevention and management of diarrhoea needed that is now being integrated into the • Case management of severe acute malnutrition health system. Vertical programmes may also • Comprehensive care of children exposed to or infected with HIV provide a platform to incrementally build on Health and multisector actions other child health priority interventions.32 • Ensuring food security for the family (or mother and child) • Maternal education Quality of services • Safe drinking water and sanitation Poor quality of care is a critical barrier to chil- • Hand washing with soap dren’s utilisation of health services and to • Reduced household air pollution health outcomes in many low and middle • Health education in schools income countries. Provision of high quality services for children requires a competent and *Preconception care includes birth spacing and preventing teenage pregnancy, promotion of contraceptive use, optimisation of weight and micronutrient status, prevention and management of infectious diseases, and screening for and managing chronic conditions motivated health workforce, availability of essential medicines and physical resources, evidence based standards of care, an action- Table 2 | Coverage of essential interventions in countries with latest survey since 200840 able health information system, and a func- Indicator No of countries with data Median (range) % coverage tional referral system. Quality improvement Demand for family planning satisfied 54 64 (13-95) processes should be embedded at all levels of Antenatal care ≥4 visits 48 53 (15-94) service provision and be supported by appro- Skilled attendant at birth 60 84 (43-94) priate managerial responses at subnational Postnatal visit newborn 17 30 (5-83) and national levels. Several strategies and Exclusive breast feeding 51 41 (3-85) approaches have been proposed to guide qual- Measles immunisation (first dose) 75 84 (42-99) ity improvement in health services.33 Pro- Antibiotic treatment for pneumonia 40 46 (7-88) grammes need to examine the effectiveness Oral rehydration therapy for diarrhoea 45 47 (12-76) and cost of various approaches and determine Malaria treatment (first line) 35 32 (3-97) which are most relevant in their context, with a view to long term feasibility and sustainabil- Integrated delivery of services treatment interventions during visits with ity. Many of these approaches primarily iden- The purpose of integration is to meet chil- sick children.29 The aim is for children to tify barriers to high quality care and then dren’s needs in a holistic manner and pro- receive appropriate interventions, ideally at implement quality improvement activities to vide services together for effectiveness, a “one stop shop.” Similarly, routine immu- overcome these barriers on the basis of “plan- quality, and efficiency.28 Integration spans nisation outreach sessions have been used to do-study-act” cycle models.34 Integrated man- not only the levels of care (community, pri- deliver interventions such as health promo- agement of childhood illness needs to be mary, and referral) but also the child’s life tion, insecticide treated nets, vitamin A sup- implemented at first level facilities, with (pre-pregnancy to childhood). Integrated plementation, and treatment of common improvements in triage, diagnosis, treatment management of childhood illness and inte- childhood illnesses.30 Recent evidence guidelines, paediatric audits, monitoring, and grated community case management are strongly supports linking these integrated follow-up at hospital level to improve paediat- examples of integration of preventive and case management platforms and strategies ric quality of care.

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Box 2: Strategies for tackling key emerging priorities in child health their efforts and creating incentives and framework for integrated approaches to child Congenital anomalies health. The year 2015 should be a turning • Optimisation of maternal nutrition to prevent low birth weight point towards a reinvigorated agenda in • Periconception supplementation with folic acid which children are enabled not only to sur- • Minimising and reducing exposure to harmful environment and substances vive but also to thrive. • Preconception and periconception maternal screening We thank Samira Aboubaker, Shamim Qazi, Nigel Rollins, • Newborn screening (for example, for hypothyroidism and haemoglobinopathies) Juana Willumsen, David Meddings, and Michael Merson for their comments on the draft manuscript. Injuries Contributors and sources: The authors all contributed • Policy and regulations to prevent and reduce risks of injuries and accidents to the article. WMW coordinated the overall preparation • Setting standards for safe environments and recreation areas for children of the manuscript. WMW, BD, RB, and CBP wrote the • Developing better road infrastructure draft, and all authors reviewed and substantially contributed to the finalisation of the manuscript. WMW • Health education on risks of injuries, burns, and drowning is the guarantor. Overweight and obesity Competing interests: We have read and understood • Appropriate policies and regulations on marketing of unhealthy foods and beverages to children and BMJ policy on declaration of interests and have no ensuring availability of healthy and nutritious choices relevant interests to declare. • Limitation of energy intake from total fats and sugars Provenance and peer review: Not commissioned; externally peer reviewed. • Increase in consumption of fruit and vegetables, as well as legumes, whole grains, and nuts The authors alone are responsible for the views • Reducing the fat, sugar, and salt content of complementary foods and other processed foods expressed in this article, which does not necessarily • Ensuring that healthy and nutritious choices are available and affordable to all consumers represent the views, decisions, or policies of WHO or the • Practising child and school food and beverage policies institutions with which the authors are affiliated. 1 • Increased regular physical activity and reduced screen time Wilson M Were medical officer, child health services Bernadette Daelmans coordinator policy, planning and Promoting equity and “every newborn action plan” to promote programme1 The concept of universal health coverage universal coverage of high quality maternal Zulfiqar A Bhutta director2, 3 calls for all people to be able to access and newborn care38 39 ; the “global action Trevor Duke professor of paediatrics and clinical director4 essential health services without undue plan for the prevention and treatment of Rajiv Bahl coordinator, research and development1 financial hardship. However, large inequal- pneumonia and diarrhoea” to prevent and Cynthia Boschi-Pinto medical officer, child epidemiology1 ities between poor and better off children treat pneumonia and diarrhoea22 ; a “com- Mark Young senior health specialist and chief, child 5 exist, both between and within countries.35 prehensive implementation plan on mater- health unit Understanding the key drivers of these nal, and infant and young child nutrition” to Eric Starbuck adviser, child health and pandemic preparedness6 inequities is necessary to identify appropri- reduce undernutrition and obesity40 ; the Maharaj K Bhan national science professor7 ate actions. Evidence has shown the effec- Global Technical Strategy for Malaria to 1Department of Maternal, Newborn, Child and tiveness of multidimensional approaches reduce global malaria case incidence and Adolescent Health, World Health Organization, Geneva, that may include conditional cash trans- mortality by 203041 ; and the Global Vaccine Switzerland fers, voucher schemes, microcredit, out- Action Plan to prevent childhood diseases 2Center for Global Child Health, Hospital for Sick reach services, and targeted community through vaccination.42 These global initia- Children, Toronto, ON, Canada health services.36 tives and action plans must be effectively 3Center of Excellence in Women and Child Health, Aga Khan University, Karachi, Pakistan articulated in national plans and the new 4Centre for International Child Health, Department of Innovations Global Strategy for Women’s, Children’s and Paediatrics, University of Melbourne, Melbourne, VIC, Improved delivery of child services will Adolescents’ Health, and the emerging child Australia require continuous innovation, and the most health priorities must be embraced. 5Health Section, United Nations Children Fund (UNICEF), promising innovations need to be supported, New York, NY, USA tested, used, and refined in countries. Inno- Conclusions 6Department of Global Health, Save the Children, vations such as digital systems (including The next 15 years provide a unique opportu- Fairfield, CT, USA 7 mobile health) have potential to strengthen nity for the global community to overcome Indian Institute of Technology, New Delhi, India health systems, reduce barriers to access, health challenges affecting children aged Correspondence to: W M Were [email protected] and strengthen monitoring and evaluation. 0-10 years. The unfinished agenda of prevent- 1 UNICEF, World Bank, UN-DESA Population Division. Levels and trends in child mortality 2014. UNICEF, Development of dispersible child friendly able child mortality should remain a priority, 2014. medicines, adaption of existing vaccines for with a focus on those countries and popula- 2 Lalonde AB. Global strategy for women’s and children’s health. J Obstet Gynaecol Can 2010;32:1130-1. use in resource poor settings, and point of tions in greatest need. At the same time, 3 GBD 2013 Mortality and Causes of Death Collaborators. care tests to improve early diagnosis and increased attention should be given to emerg- Global, regional, and national age-sex specific treatment are among the priorities for ing child health priorities. Governments and all-cause and cause-specific mortality for 240 causes of death, 1990-2013: a systematic analysis for the increasing access, quality, and coverage. the global community at large must invest in Global Burden of Disease Study 2013. Lancet the health of their children. The sustainable 2015;385:117-71. 4 Grantham-McGregor S, Cheung YB, Cueto S, et al. Global initiatives and action plans to achieve development goals, by virtue of their inter- Developmental potential in the first 5 years for 2015-30 targets sectoral and integrated approach, provide an children in developing countries. Lancet 2007;369:60-70. Moving beyond 2015, the global community excellent opportunity to mobilise the actions 5 World Health Organization. Global Health Observatory has set goals and targets for tackling the necessary to provide children with the ser- (GHO) data. www.who.int/gho/child_health/en/index.html. unfinished child survival agenda to achieve vices and the care they need and to leave no 6 World Health Organization, Partnership for Maternal, Newborn and Child Health, Aga Khan University. under 5 mortality of 25 or less per 1000 live child behind. Governments, development Essential interventions, commodities and guidelines births by 2030.37 This momentum has been partners, donors, multilateral agencies, UN for reproductive, maternal, newborn and child health (RMNCH). PMNCH, 2011 (available at www.who.int/ translated into several global initiatives: agencies, and non-governmental organisa- pmnch/knowledge/publications/201112_essential_ “ending preventable maternal mortality” tions have important roles to play in aligning interventions/en/).

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7 World Health Organization. Compilation of WHO 20 Lassi ZS, Kumar R, Mansoor T, et al. Essential interventions: 32 Gounder CR, Chaisson RE. A diagonal approach to recommendations on maternal, newborn, child and implementation strategies and proposed packages of building primary healthcare systems in resource- adolescent health. 2013. www.who.int/maternal_child_ care. Reprod Health 2014;11(suppl 1):S5. limited settings: women-centred integration of HIV/ adolescent/documents/mnca-recommendations/en. 21 Marmot M. Closing the health gap in a generation: the AIDS, tuberculosis, malaria, MCH and NCD initiatives. 8 World Health Organization. Universal health coverage. work of the Commission on Social Determinants of Trop Med Int Health 2012;17:1426-31. 2014. www.who.int/universal_health_coverage/en/. Health and its recommendations. Glob Health Promot 33 Althabe F, Bergel E, Cafferata ML, et al. Strategies for 9 Partnership for Maternal, Newborn and Child Health. 2009;suppl 1:23-7. improving the quality of health care in maternal and Report of feedback from consultation on draft zero of 22 World Health Organization. Ending preventable child health in low- and middle-income countries: an the Global Strategy for Women’s, Children’s and deaths from pneumonia and diarrhoea by 2025. overview of systematic reviews. Paediatr Perinat Adolescents’ Health. 2015. www.who.int/pmnch/ WHO, 2013 (available at www.who.int/maternal_ Epidemiol 2008;22(suppl 1):42-60. activities/advocacy/globalstrategy/2016_2030/en/. child_adolescent/news_events/news/2013/ 34 Taylor MJ, McNicholas C, Nicolay C, et al. Systematic 10 Liu L, Oza S, Hogan D, et al. Global, regional, and gappd_launch/en/). review of the application of the plan-do-study-act national causes of child mortality in 2000-13, with 23 Gill CJ, Young M, Schroder K, et al. Bottlenecks, barriers, method to improve quality in healthcare. BMJ Qual projections to inform post-2015 priorities: an updated and solutions: results from multicountry consultations Saf 2014;23:290-8. systematic analysis. Lancet 2015;385:430-40. focused on reduction of childhood pneumonia and 35 Victora CG, Barros AJ, Axelson H, et al. How changes 11 Santosa A, Wall S, Fottrell E, et al. The development and diarrhoea deaths. Lancet 2013;381:1487-98. in coverage affect equity in maternal and child experience of epidemiological transition theory over 24 Perry HB, Zulliger R, Rogers MM. Community health health interventions in 35 Countdown to 2015 four decades: a systematic review. Glob Health Action workers in low-, middle-, and high-income countries: countries: an analysis of national surveys. Lancet 2014;7:23574. an overview of their history, recent evolution, and 2012;380:1149-56. 12 Sahoo K, Sahoo B, Choudhury AK, et al. Childhood current effectiveness. Annu Rev Public Health 36 Yuan B, Målqvist M, Trygg N, et al. What interventions obesity: causes and consequences. J Family Med Prim 2014;35:399-421. are effective on reducing inequalities in maternal Care 2015;4:187-92. 25 Gilmore B, McAuliffe E. Effectiveness of community health and child health in low- and middle-income 13 Peden M, Oyegbite K, Ozanne-Smith J, et al, eds. World workers delivering preventive interventions for maternal settings? A systematic review. BMC Public Health report on child injury prevention. World Health and child health in low- and middle-income countries: a 2014;14:634. Organization, 2008 (available at whqlibdoc.who.int/ systematic review. BMC Public Health 2013;13:847. 37 UNICEF. Committing to child survival: a promise publications/2008/9789241563574_eng.pdf). 26 Lewin S, Munabi-Babigumira S, Glenton C, et al. Lay renewed—progress report 2012. UNICEF, 2012 (available 14 Ng M, Fleming T, Robinson M, et al. Global, regional, health workers in primary and community health care at www.unicef.org/publications/index_65820.html). and national prevalence of overweight and obesity in for maternal and child health and the management of 38 World Health Organization, UNICEF. Every newborn: an children and adults during 1980-2013: a systematic infectious diseases. Cochrane Database Syst Rev action plan to end preventable deaths. WHO, 2014 analysis for the Global Burden of Disease Study 2013. 2010;3:CD004015. (available at www.everynewborn.org/Documents/ Lancet 2014;384:766-81. 27 Bhandari N, Mazumder S, Taneja S, et al. Effect of Full-action-plan-EN.pdf). 15 Lassi ZS, Mallick D, Das JK, et al. Essential interventions implementation of Integrated Management of Neonatal 39 World Health Organization. Strategies toward ending for child health. Reprod Health 2014;11(suppl 1):S4. and Childhood Illness (IMNCI) programme on neonatal preventable maternal mortality (EPMM). WHO, 2015 16 Lassi ZS, Mansoor T, Salam RA, et al. Essential and infant mortality: cluster randomised controlled (available at who.int/reproductivehealth/topics/ pre-pregnancy and pregnancy interventions for trial. BMJ 2012;344:e1634. maternal_perinatal/epmm/en/). improved maternal, newborn and child health. Reprod 28 Dudley L, Garner P. Strategies for integrating primary health 40 McGuire S. World Health Organization. Comprehensive Health 2014;11(suppl 1):S2. services in low- and middle-income countries at the point implementation plan on maternal, infant, and young 17 Kendrick D, Mulvaney CA, Ye L, et al. Parenting of delivery. Cochrane Database Syst Rev 2011;7:CD003318. child nutrition. Geneva, Switzerland, 2014. Adv Nutr interventions for the prevention of unintentional 29 Atun R, de Jongh TE, Secci FV, et al. Integration of 2015;6:134-5. injuries in childhood. Cochrane Database Syst Rev priority population, health and nutrition interventions 41 World Health Organization. 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Realising the health and wellbeing of adolescents Investing in adolescents’ health and development is key to improving their survival and wellbeing and critical for the success of the post-2015 development agenda, argue Laura Laski and colleagues

dolescence is a critical stage of life the capabilities required for a productive, Mental health and self harm characterised by rapid biological, healthy, and satisfying life. We call for a Although half of all mental health disorders emotional, and social develop- global, participatory movement to improve in adulthood start by age 14, most remain ment. It is during this time that the health of the world’s adolescents as part undetected and untreated. Depression is the every person develops the capa- of a broader agenda to improve their wellbe- top cause of illness and disability among Abilities required for a productive, healthy, ing and uphold their rights. adolescents, and suicide is the leading cause and satisfying life. In order to make a healthy of death among adolescent girls aged 15-19 transition into adulthood, adolescents need Methods and the third cause of death among all ado- to have access to health education, including This paper is based on the review of evi- lescents 10-19 globally.4 education on sexuality;1 quality health ser- dence based inputs received from public vices, including sexual and reproductive; consultations conducted by the Partner- Communicable and non-communicable and a supportive environment both at home ship for Maternal, Newborn and Child diseases and in communities and countries. Health and expert meetings organised by Childhood immunisation has brought down The global community increasingly recog- the UN Population Fund (UNFPA) in 2015 as adolescent deaths and disability signifi- nises these vital needs of adolescents, and part of the UN secretary general’s Global cantly,4 but common infectious diseases that there is an emerging consensus that invest- Strategy for Women’s, Children’s and Ado- have been a focus for action in young chil- ing intensively in adolescents’ health and lescents’ Health. The consultations brought dren are still killing adolescents. For exam- development is not only key to improving together leaders in adolescent health from ple, diarrhoea and lower respiratory tract their survival and wellbeing but critical for governments, civil society organisations, infections are estimated to rank second and the success of the post-2015 development UN agencies (including­ H4+, a partnership fourth, respectively, among causes of death agenda.2 The suggested inclusion of adoles- between UNAIDS, UNFPA, Unicef, the in 10-14 year olds globally.4 Adolescents who cent health in the United Nations secretary World Health Organization, UN Women, are sexually active have the highest rates of general’s Global Strategy for Women’s and and the World Bank that helps countries prevalent and incident human papillomavi- Children’s Health is an expression of this improve their health services for women, rus (HPV) infections, with 50-80% having growing awareness and represents an children, and newborns), donors, academ- infections within three years of initiating unprecedented opportunity to place adoles- ics and other researchers, private sector sexual intercourse.7 cents on the political map beyond 2015. organisations, and young people and built The health related behaviours that under- Ensuring that every adolescent has the consensus on priority actions needed to lie major non-communicable diseases usu- knowledge, skills, and opportunities for a protect and promote the health of adoles- ally start during adolescence: tobacco and healthy, productive life and enjoyment of all cents and youth. alcohol use and diet and exercise patterns human rights3 is essential for achieving potentially leading to overweight and obe- improved health, social justice, gender Health challenges faced by adolescents sity. These habits could affect the morbidity equality, and other development goals. Adolescents have benefited less than and mortality of adolescents later in their We argue that the priority in the revised younger children from the “epidemiological lives as well as of future generations. Anae- Every Women Every Child Global Strategy transition” that has reduced all causes of mia, resulting from rapid growth during ado- needs to be giving adolescents a voice, mortality among children.3 In 2012, an esti- lescence combined with a lack of iron, affects expanding their choices and control over mated 1.3 million adolescents died mostly girls and boys and is the third cause of years their bodies, and enabling them to develop from preventable or treatable causes.4 We set lost to death and disability.4 out the major health problems below.5 Key messages Maternal mortality and morbidity Injuries and violence In low and middle income countries high Adolescents aged 10-19 years have Unintentional injuries are a leading cause of adolescent birth rates reflect both a lack of specific needs and health systems need mortality and morbidity during the second opportunities available to girls and vulnera- to take into account their biological, emotional, and social development decade of life. Road traffic injuries are the bilities they experience during adolescence top cause of death among adolescents, with and beyond. Every day in developing coun- Interventions to support adolescents to some 330 adolescents dying every day. tries, 20 000 girls under age 18 give birth. attain a productive, healthy, and satisfying An estimated 180 adolescents die every Girls under 15 account for two million of the life are critical to the success of the day from interpersonal violence.5 At least annual total of 7.3 million new adolescent sustainable development agenda one in four boys aged 15-19 said they had mothers; if current trends continue, the Priorities for action include health experienced physical violence since age 15.6 number of births to girls under 15 could rise education, access to health services, Worldwide, up to 50% of sexual assaults are to three million a year in 2030.8 immunisation, nutrition, and committed against girls under 16, and some Pregnancy, whether intended or not, puts psychological support 30% of girls aged 15-19 experience violence adolescents at risk of death and injury, Action is also needed in other sectors, by a partner.4 Moreover, many girls’ first sex- including conditions such as obstetric fistula. particularly education ual experience is forced and coerced. Maternal mortality is the second leading

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cause of death among adolescent girls aged violence, respect for human rights, and will not come to the services. Variability in 15-19 years.4 Around 11% of births worldwide, promotion of gender equality. Promotion quality can be minimised by setting stan- or an estimated 16 million, are to girls aged of and opportunities for physical activity dards and supporting their achievement.4 15-19,9 10 and very young mothers are the should be also included in schools and Individual, interpersonal, community, most likely to experience complications and communities organisational, and structural factors affect die of pregnancy related causes.11 Adolescent • Access to and use of integrated health ser- how adolescents access care, how they girls have high rates of complications from vices—As adolescents become sexually understand information, what information pregnancy, delivery, and unsafe abor- active, they require an integrated package they receive, which channels of information tion.4 10 12 The consequences have implica- of services, especially sexual and repro- influence their behaviours, and how they tions for future generations, as newborns and ductive health services. This includes think about the future and make decisions in infants of adolescent mothers are at higher access to an expanded mix of contracep- the present. To improve acceptability and risk of low birth weight and mortality.13 Gaps tives, including emergency contraception quality of health services, health workers, in the fulfilment of sexual and reproductive and long acting reversible contraceptives; particularly primary care workers, need to be health undermine the achievement of gender safe abortion where legal, and manage- trained and supported in protecting adoles- equality, drain household incomes and pub- ment of the consequences of unsafe abor- cents’ privacy and confidentiality and in lic budgets, lead to poor health and educa- tion; maternity care; testing and treatment treating them with respect and without judg- tional outcomes, lower productivity and of sexually transmitted infections, includ- ment.4 labour force participation, and result in ing HIV testing, diagnosis, counselling, Financial and legal barriers also need to missed opportunities for economic growth.14 care, and post-exposure prophylaxis; and be tackled. Adolescents may not be covered care after gender based or sexual violence by an effective prepaid pooling arrangement, HIV-AIDS • Immunisation—HPV vaccination for 10-14 such as insurance schemes, or be able to Although there has been a 43% decline in year olds protects them from developing meet out of pocket expenses.20 Financial new HIV infections among adolescents since cervical cancer as adults. HPV vaccination protection to cover the services needed by 2000, globally, there are twice as many new is also an opportunity to reach adoles- adolescents should be part of universal infections as deaths from AIDS.14 In 2013, an cents with other interventions such as health coverage.4 In some countries, govern- estimated 2.1 million adolescents between menstrual hygiene, deworming, and ments restrict access of adolescents to health the ages of 10 and 19 years were infected with malaria prevention. Other critical vaccines services, especially sexual and reproductive HIV. In 2014, HIV/AIDS was estimated to be include tetanus booster, rubella, and hep- services, by requiring the consent of parents, the second leading cause of death globally.4 atitis B (if not previously vaccinated), or spouses if they are married. Adolescents, especially adolescent girls, are measles, and meningococcal disease the only population group for which AIDS (depending on epidemiology) Non-health sector interventions related deaths are not falling.15 Young • Nutrition—Developing healthy eating and Numerous factors outside the health sector women and adolescent girls are dispropor- exercise habits at this age are foundations protect or undermine the health of adoles- tionately vulnerable and at high risk.16 for good health in adulthood and protect cents.21 Short and long term risks arise from against overweight and obesity. Nutri- economic (poverty, inequality), sociocul- Interventions to protect and promote health tional supplementation, particularly iron tural (gender, early marriage), biological In the past 20 years, governments and the and folic acid, is important to prevent (prevalence of malaria, water borne hel- international community have made clear anaemia and protect the health of their minths, HIV, etc) physical, environmental commitments to adolescents and their future offspring (should they choose to (such as road conditions, housing, and pol- health.1 4 5 8-10 17 18 Evidence shows that posi- have children) lution), legal, and policy factors, but educa- tive health outcomes for adolescents • Psychosocial support—Mental health tion is the principal socioeconomic require intervention from not only health problems in adolescence should be determinant of adolescent health. but other sectors, including education and detected and managed by competent A good education gives young people the workforce. health workers.5 Schools and other com- skills and knowledge to enable them to miti- To ensure adolescents have a voice, choice, munity settings can also help in promot- gate health risks and to seek health and and control over their bodies and are enabled ing good mental health social services when faced with these prob- to develop the capabilities required for a pro- lems. The longer a girl stays in school, the ductive, healthy, and satisfying life, global Creating health systems suited to greater the chances that she uses modern efforts should focus on reducing adolescent adolescents contraception if she has sex, and the lower deaths and morbidity and creating a support- Availability of good quality care and health- her chances of giving birth as an adoles- ive legal and social climate for positive ado- care workers trained to deal with adoles- cent.17 Early (and often forced) marriage is a lescent development. Key interventions need cents is critical for delivering effective health serious contributing problem to school to span the health sector to social determi- interventions. Efforts to improve adolescent retention and health. Fifty one countries nants of health, to other actors such as par- health require health systems that are have rates of early marriage (before age 18) ents and community members. Based on an responsive to adolescents.4 Stigma, discrim- that are above 25%, and nine out of 10 ado- analysis of problems and opportunities, we ination, judgmental treatment, lack of confi- lescent births take place in the context of suggest the following priority actions: dentiality, and inability to physically access early marriages.18 Schools must become a services have been shown to be important safe place for girls and should enable preg- • Health education, including comprehensive barriers to care.19 Evidence from both high nant girls to pursue their education in a sup- sexuality education—Adolescence is an and low income countries shows that ser- portive environment. appropriate time to learn about healthy vices for adolescents are highly fragmented, Adolescents need quality education and diets, the consequences of alcohol and poorly coordinated, and uneven in quality.4 schooling at least to secondary level. Younger substance misuse, resisting peer pressure Outreach and non-facility based services are adolescent girls in particular may need extra and bullying, healthy sexuality, sexual important to reach adolescents who otherwise support to stay in school, and all adolescents

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need a range of economic and social assets public spaces, setting lower maximum violence, and to help create and sustain such as financial literacy, life skills, safe blood alcohol concentration levels for national and global peace. In turn, this spaces, social networks, and economic capi- young drivers, and regulating marketing healthy generation will nurture the next so tal. Vocational training is also important to of foods high in saturated fats, trans-fatty that it can participate effectively in a rapidly prepare adolescents for decent paid employ- acids, sugar, or salt) changing globalised world. ment and self employment after they reach • Revise and implement laws on child mar- Competing interests: I have read and understood BMJ working age. riage—The minimum age at marriage policy on declaration of interests and have no relevant Communities and schools must be should be universally set at 18 for both interests to declare. equipped with safe water and sanitation, boys and girls. Exceptions to marry with Contributors and sources: The members of the expert consultative group for Every Woman Every Child on which promotes good hygiene, and particu- consent from parents should not be Adolescent Health were L Laski, United Nations lar challenges for menstruating girls must be included in marriage laws. As part of civil Population Fund, New York; Z Matthews and S Neal, addressed. Appropriate spaces and facilities registration and vital statistics efforts, University of Southampton, UK; G Adeyemo, Save the Children, Nigeria; G Patton, University of Melbourne; S for physical activity need to be in place to birth and marriage registration should be Sawyer, Centre for Adolescent Health, Royal Children’s promote and enable safe and healthy exer- made mandatory Hospital, Parkville, Australia; N Fuchs-Montgomery. cise practices. • Make adolescents visible in policy formula- Family Planning Program at the Bill and Melinda Gates tion and monitoring Use existing data on Foundation; A Capasso, Family Care International, New Parents and tutors have a critical role in — York; S Gold, International Women’s Health Coalition, raising healthy children. In the challenging adolescents from censuses, demographic New York; S Petroni, International Center for Research on adolescent years, parents need support, and health surveys, and multiple indicator Women; L Say, R Khosla, and V Chandra Mouli, cluster surveys to formulate policy and Department of Reproductive Health and Research, WHO; information, skills, and resources to func- B J Ferguson, Department for Maternal, Newborn, Child tion effectively. Investment in support activi- deliver programmes. Dedicated surveys and Adolescent Health, WHO; M Melles, United Nations ties for parents is an important component of such as the global school-based student AIDS agency; S Kasedde, T Oyewale, N Yasrebi, and S programmes for adolescents, to prevent health surveys are needed to overcome the Lehtimaki, United Nations Children’s Fund; D Engel, S Chalasani, P Awasti, and L Sharaf, United Nations interpersonal violence and promote good lack of data, especially on younger adoles- Population Fund. 22 mental and sexual health. Support (both cents and other subpopulations of adoles- Provenance and peer review: Not commissioned; practical and legal) also needs to be pro- cents, such as head of households, those externally peer reviewed. vided for those affected by harmful tradi- living without their parents, domestic The authors alone are responsible for the views tional practices and violence, including workers or migrants, refugees, those living expressed in this article, which does not necessarily trafficking. Over the next five years, interven- with disabilities, and trafficked adoles- represent the views, decisions, or policies of WHO or the institutions with which the authors are affiliated. tions must be prioritised for places where cents. Laura Laski chief, sexual and reproductive health child marriage is prevalent, including keep- branch, Technical Division, United Nations Population ing girls in school and equipping them with Building a new monitoring framework Fund, New York, USA. the knowledge and ability to exercise their We need a unified platform that allows coun- On behalf of the Expert Consultative Group for Every rights as adolescents. Finally, adolescents tries to come together and pursue a contex- Woman Every Child on Adolescent Health. must be given the opportunity to participate tually relevant yet common agenda on Correspondence to: L Laski [email protected] in decision making and be encouraged to adolescent health. The global strategy pres- Additional material is published online only. To view please participate in the political process once they ents just such a platform, convening and visit the journal online (http://dx.doi.org/10.1136/bmj.h4119) have reached the legal age. leading countries in a global call to action on 1 World Health Organization. Sixty fourth World Health indicators related to adolescent health in the Assembly. Resolution WHA 64.28: youth and health risks. 2011. http://apps.who.int/gb/ebwha/ Policies and laws protecting the health of sustainable development goals accountabil- pdf_files/WHA64/A64_R28-en.pdf. adolescents ity framework. Four of the sustainable devel- 2 McCoy D. The high level taskforce on innovative international financing for health systems. Health Adolescents are neither children nor adults; opment goals include clearly stated targets Policy Plan 2009;24:321-3. their needs can be easily overlooked in poli- for adolescent health (see appendix on 3 Viner R, Coffey C, Mathers C, et al. 50-year mortality cies. Health interventions for adolescents thebmj.com for details). trends in children and young people: a study of 50 low-income, middle-income, and high-income cannot be effectively implemented without Given the extent of change across adoles- countries. Lancet 2011;377:1162-74. the appropriate policy and legal environ- cence, these health targets must be mea- 4 World Health Organization. Health for the world’s adolescents: a second chance in the second decade. ment and its effective application. In this sured separately in adolescents aged 10-14 2014. www.who.int/maternal_child_adolescent/ regard countries need to take the following and 15-19 years so that we can monitor coun- topics/adolescence/second-decade/en/. actions: tries’ progress. 5 World Health Organization. Adolescents: health risks and solutions. Fact sheet No 345. 2014. www.who.int/ mediacentre/factsheets/fs345/en/. • Enable access to health services—Examine Conclusions 6 Unicef. Hidden in plain sight: a statistical analysis of violence against children. 2014. www.unicef.org/ and potentially revise current policies to The inclusion of adolescent health in the UN publications/index_74865.html. remove mandatory third party authorisa- secretary general’s Global Strategy on Wom- 7 Anna-Barbara Moscicki. HPV Infections in Adolescents. Disease Markers. 2007;23(4):229-34. tion for sexual and reproductive health en’s and Children’s Health and targets 8 UNFPA State of the World Population. Motherhood in services and adopt flexible policies to directly linked to adolescent health in the childhood. 2013 www.unfpa.org/sites/default/files/ allow adolescents to be considered post-2015 sustainable development goals pub-pdf/EN-SWOP2013-final.pdf 9 Unicef. Committee on the rights of the child “mature minors” agenda represent an unprecedented oppor- 33rd session: General comment No 4. 2003. www. • Control exposure to unhealthy products— tunity to step up efforts to adopt policies for unicef.org/adolescence/files/CRCCommitAdolesc.doc. 10 World Health Organization. WHO guidelines on Enact and enforce laws on use of tobacco, adolescents. By developing programmes to preventing early pregnancy and poor reproductive alcohol, and illegal substances and food provide them with the skills they need for outcomes among adolescents in developing countries. policies to reduce exposure to dangerous their health and development countries can 2011. www.who.int/immunization/hpv/target/ preventing_early_pregnancy_and_poor_reproductive_ and unhealthy substances (such as raising ensure adolescents will contribute fully to outcomes_who_2006.pdf. taxes on tobacco and alcohol, prohibition their societies and develop the judgment, 11 Vogel J, Pileggi-Castro C, Chandra-Mouli V, et al. Millennium development goal 5 and adolescents: of sale to people below an appropriate values, behaviours, and resilience they looking back, moving forward. Arch Dis Childhood minimum age, prohibiting smoking in need to be safe, to end discrimination and 2015;100(suppl 1):S43-7.

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12 Grimes D, Benson J, Singh S, Romero M, Ganatra B, 16 UNAIDS. The gap report. 2014. www.unaids.org/sites/ 20 Waddington C, Sambo C. Financing health care Okonofua F et al. Unsafe abortion: the preventable default/files/en/media/unaids/contentassets/ for adolescents: a necessary part of universal pandemic. Lancet 2006;368:1908-19. documents/unaidspublication/2014/ health coverage. Bull World Health Organ 2014;93:​ 13 UNFPA. Population dynamics in the least developed UNAIDS_Gap_report_en.pdf. 57-9. countries: challenges and opportunities for 17 UNFPA. State of the World Population. The power of 1.8 21 Viner R, Ozer E, Denny S, et al. Adolescence and the development and poverty reduction. 2011. billion—adolescents, youth, and the transformation of social determinants of health. Lancet www.unfpa.org/sites/default/files/pub-pdf/ the future. 2014. www.unfpa.org/sites/default/files/ 2012;379:1641-52. CP51265.pdf. pub-pdf/EN-SWOP14-Report_FINAL-web.pdf. 22 WHO. Helping parents in developing countries improve 14 High Level Task Force for ICPD. Smart investments 18 UNFPA. Marrying too young. 2011 www.unfpa.org/ adolescents’ health. 2007 http://apps.who.int/iris/ for financing the post-2015 development agenda. sites/default/files/pub-pdf/MarryingTooYoung.pdf. bitstream/10665/43725/1/9789241595841_eng. 2015. http://icpdtaskforce.org/wp-content/ 19 International Planned Parenthood Foundation, CORAM. pdf?ua=1&ua=1 uploads/2015/01/FinancingBriefSmartInvestments​ ​ Over-protected and under-served. A multicountry study 2015.pdf. on legal barriers to young people’s access to sexual Cite this as: BMJ 2015;351:h4119 15 Mahy M, Idele P. Epidemiological summary: HIV among and reproductive health service. 2014. www. adolescents (10-19 years). ALL-IN Global Strategy childrenslegalcentre.com/userfiles/file/ippf_coram_ Consultation, 2014. uk_report_web.pdf.

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Ending preventable maternal and newborn mortality and stillbirths Doris Chou and colleagues discuss the strategic priorities needed to prevent maternal and newborn deaths and stillbirths and promote maternal and newborn health and wellbeing

espite remarkable achievements to Key themes and strategic objectives that 2500 g at birth, especially those born preterm improve maternal and child sur- were found to be largely similar are dis- (fig 1).13 vival, 800 women and 7700 new- cussed in this paper. Where the emphasis or Stillbirths have declined by only 15% since borns still die each day from recommended strategic approach varied 1995. An estimated 2.6 million stillbirths complications during pregnancy, based on the target population, and the dis- occurred globally in 2009, of which 40% childbirth,D and in the postnatal period; an addi- tinctions were deemed important, specific were intrapartum and probably due to inad- tional 7300 women experience a stillbirth.1-3 recommendations were retained. equate care.3 14 In addition to prolonged and Some countries have been able to improve Both strategic plans are based on scien- obstructed labour, untreated infections such health outcomes for women and children, even tific and empirical evidence, and underwent as syphilis are an important cause of still- with relatively low health expenditures.4 The wide expert consultation with inputs from births in low resource settings.14 key to their success can be found in context spe- national, regional, and global meetings, and Optimal quality of care around childbirth cific, evidence informed strategies to improve an official online consultation.7 8 9 The mor- and in the neonatal period could avert and integrate care, supported by strong guiding tality targets were endorsed by countries, 113 000 maternal deaths, 531 000 stillbirths, principles and good governance.5 including at the 67th World Health Assembly and 1.3 million newborn deaths by 2020.15 This paper builds upon two strategic in 2014.10 Furthermore, satisfying the unmet need for plans—Every Newborn: An Action Plan to family planning could prevent 29% of mater- End Preventable Deaths (ENAP) and the Limited progress nal deaths a year.16 Effective care that pre- Strategies toward Ending Preventable Mater- As the era of the millennium development vents mortality will also prevent maternal nal Mortality (EPMM)6 7—that aim to catalyse goals comes to a close, more needs to be and neonatal morbidities and improve child global action to eliminate wide disparities in done for women’s and children’s health. neurodevelopmental outcomes and long the risk of death and end preventable mater- Although maternal deaths declined to term adult wellbeing.13 17 18 The health and nal and newborn mortality and stillbirths 289 000 in 2013,1 the 45% reduction in survival of babies and their mothers are within a generation (box 1). We discuss the maternal mortality since 1990 falls far short inextricably linked, calling for coordinated strategic priorities and essential interven- of the target of 75% in millennium develop- care before and during pregnancy, in child- tions needed to prevent maternal and new- ment goal 5. The majority of maternal deaths birth, and in the postnatal period. born deaths and stillbirths and promote are still due to direct obstetric causes—that maternal and newborn health and wellbeing. is, haemorrhage (27%), hypertensive disor- Strategic priorities ders (14%), sepsis (11%), and complications Evidence based strategy must inform plan- Methods of abortion (8%).11 However, a rising number ning for maternal and newborn health and A complete review and mapping of the ele- of deaths are related to chronic health condi- survival, with due consideration of health ments of ENAP and EPMM was undertaken. tions in pregnancy, such as diabetes, HIV, system dynamics and social and environ- malaria, cardiovascular conditions, and obe- mental risk factors in different countries.19 Key messages sity (fig 1). Financial security and health equity are Newborn deaths have declined by 40% essential. The sustainable development Unacceptable levels of maternal and since 1990; about 2.8 million newborns died goals provide a framework for universal newborn mortality and stillbirths impede in 2013. The fall in newborn mortality has health coverage described by three, inter- the realisation of healthy and sustainable been slower than that in child mortality, and linked objectives—enhancing the quality societies newborn deaths now account for 44% of all and availability of essential health services; Achieving country and global targets for deaths in children under 5 globally.2 The achieving equitable and optimal uptake of ENAP and EPMM will contribute to the three main causes of newborn deaths are services in relation to need; and improving goals of the Global Strategy for Women’s, preterm birth complications (35%), intrapar- cost efficiencies and financial protection.20 Children’s and Adolescents’ Health tum conditions (24%), and infections The Global Financing Facility can help to We present five strategic objectives that (20%).12 Almost 80% of newborn deaths drive financial innovations to achieve the should be prioritised to end preventable occur among babies who weigh less than sustainable development goals across the maternal and newborn deaths and stillbirths, synthesised from the strategic objectives described by ENAP and EPMM Box 1 Global targets for ending preventable maternal and newborn mortality The objectives focus on strengthening care • Every country should reduce its maternal mortality ratio by at least two thirds from the 2010 baseline, around the time of birth; strengthening and no country should have a rate higher than 140 deaths per 100 000 live births (twice the global target) health systems; reaching every women • Every country should have a national neonatal mortality rate of ≤12 per 1000 live births and a stillbirth and newborn; harnessing the power of rate of ≤12 per 1000 total births parents, families, and communities; and • The global maternal mortality ratio should be <70 maternal deaths per 100 000 live births improving data for decision making and • The global neonatal mortality rate milestone will be 9 per 1000 live births and stillbirth rate 9 per 1000 accountability total births

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workforce. The lack of complete registration Causes of maternal mortality* Causes of neonatal mortality of births and deaths and accurate informa- Tetanus Diarrhoea (­%) (%) tion on causes of death to inform healthcare Complications Embolism ( %) decision making and programme evaluation Indirect Abortion Other from preterm causes birth limit the equitable delivery of essential, ‰% Congenital ‰% ­% ˆ% quality interventions to populations in need. Pneumonia % ­% % Haemorrhage Research and development is needed to ˆ% % tackle intransigent problems in the delivery Other direct % % ­% causes Sepsis/ of healthcare services and to develop tech- meningitis nologies that make birth safer, such as sim- Sepsis Hypertension Intrapartum related plified resuscitation or better drug delivery. * Other direct causes include complications of delivery ( %), obstructed labour ( %), and other direct causes (%) The global community must also explicitly Indirect causes include HIV related deaths, pre-existing diseases (%), and other indirect causes (%) describe what constitutes quality of care and skilled attendance at birth to enable appro- 11 12 Figure 1 | Causes of maternal and neonatal mortality ­ priate monitoring and evaluation, and WHO is developing standards that respond to the continuum of reproductive, maternal, new- For example, family planning will prevent quality framework published in its vision born, child, and adolescent health by 2030.21 closely spaced or ill timed pregnancies, statement (WHO, unpublished data).31 We present five priorities, synthesised which are directly correlated with increased from the strategic objectives described by mortality, and implementation of WHO’s Objective 3—Reach every woman and ENAP and EPMM (box 2). technical and policy guidelines for access to newborn safe abortion will also avert deaths.28 For Equity is a fundamental human right and a Objective 1—Strengthen care around time of newborn health, improved care around the prerequisite to achieving the sustainable birth time of childbirth and special care for small development goals. Programme planners Mothers and their babies are at highest risk and sick newborns is essential to reduce need to better understand barriers to access of death during labour, childbirth, and the mortality.8 and the personal factors that make care first week after birth. Investing in improved acceptable to all. Equity includes not just access to and quality of care around this Objective 2—Strengthen health systems access to services but provision of high qual- time, and achieving high levels of coverage Health system strengthening must tackle ity care without discrimination and meeting of effective interventions, has the potential both the hardware (essential health infra- sustained demand at scale. to avert three million deaths of women, new- structure, amenities, and commodities) and Gender equality and the empowerment of borns, and stillborn babies a year, almost software (leadership and governance, trans- women and girls are central to a rights based two million of which can be prevented parent health information, innovation and approach. Gender based violence is wide- around the time of birth (fig 2 ).15 private-public partnerships, mechanisms for spread and its adverse effects include Despite a global increase in coverage of participation and community engagement, unwanted pregnancies, pregnancy compli- skilled birth attendance, associated declines and respectful care norms and values) of cations including low birth weight and mis- in maternal mortality have been modest, and health systems.29 In addition, effective refer- carriage, maternal injury and death, and for stillbirths virtually non-existent.3 4 22 23 ral systems are needed to ensure seamless sexually transmitted infections such as HIV/ This lack of improvement highlights the coordination across time, disciplines, and AIDS.32 Strategies for empowering women in need to focus on quality of care, including facilities. their reproductive and maternal healthcare provider competencies and environments Lack of an adequate health workforce and must ensure not only the power of decision that enable provision of essential clinical access to lifesaving commodities are major making—including whether, when, and how interventions with dignity. High quality constraints in many countries. Thirty eight often to get pregnant—but the availability of healthcare is safe, effective, timely, efficient, high burden countries face critical imbal- options they need to exercise their choices. equitable, people centred, and respect- ances and shortages in the availability of The cost of health services can be a major ful.24-26 Given the inextricable link between healthcare providers.30 Nearly 90% of essen- barrier to care. Up to 11% of the population in mother and baby, care should also be admin- tial care services for maternal and neonatal some countries incur high out-of-pocket costs istered without separation of mother and health can be provided by health workers 23-25 . baby. with midwifery skills, provided they are edu- Neonatal deaths Effective healthcare for all major causes of cated to achieve international standards of Stillbirths . death will contribute to ending preventable competency and regulated to ensure their Maternal deaths 30 maternal and newborn mortality and reach- skills are maintained. Yet midwives make . ing the highest attainable level of health.11 15 27 up only 36% of the global maternity care

Lives saved (millions) .

Box 2 Priority strategic objectives  • Strengthen and invest in care around the time of birth, with a focus on improving quality and experience of care, while ensuring full integration of services for mothers and babies across the Care of small continuum of care Preconception nutrition carePregnancy care • Strengthen health systems to optimise the organisation and delivery of care, the workforce, and sick newborn commodities, and innovation birth, and in rst week • Reach every woman and newborn by minimising inequities in access to and coverage of care Care during labour, around • Harness the power of parents, families, and communities, and engage with society Figure 2 | Potential impact of intervention • Improve data for decision making and accountability packages15

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for healthcare, with as many as 5% forced maternal and perinatal death review and The authors alone are responsible for the views into poverty by health related expenditures, response mechanisms.39 40 expressed in this article, which does not necessarily represent the views, decisions, or policies of WHO or including costs associated with essential Additional global indicators are needed. the institutions with which the authors are affiliated. 33 maternal and newborn care. Universal Innovations in information technology Provenance and peer view: Not commissioned; health coverage means reaching all people in (including m-health) can strengthen health externally peer reviewed. the population with essential services and systems through effective, real time data col- Doris Chou, medical officer1 protecting them from financial hardship lection.41 Closing the loop of monitoring and Bernadette Daelmans,coordinator2 owing to the cost of these services. Perfor- evaluation through actual use of data to R Rima Jolivet,maternal health technical director3 mance based financial incentives and condi- understand the effects of interventions is Mary Kinney, senior specialist, global evidence and tional cash transfers have been effective in critical in ensuring accountability.42 advocacy4 increasing care seeking and improving qual- Lale Say, coordinator1 ity of care.34 Political and financial decision Priority interventions 1Department of Reproductive Health and Research, World Health Organization, 1211 Geneva 27, makers in countries and global donors must To achieve the targets of ENAP and EPMM an Switzerland prioritise adequate and sustainable resources essential package of effective interventions 2Department of Maternal, Newborn, Child and for maternal and newborn health. must be implemented to reach every woman, Adolescent Health, World Health Organization, pregnancy, and newborn. But the choice of Geneva Objective 4—Harness the power of parents, interventions and measures of success must 3Maternal Health Task Force, Harvard TH Chan School of families, and communities be tailored to each country based on local Public Health, Boston, MA, USA 4 Ideally, families protect and care for women context. The interventions related to mater- Save the Children, Washington, DC, USA and newborns. Men have an important role in nal and newborn care that are included in On behalf of the Every Newborn Action Plan (ENAP) and Ending Preventable Maternal Mortality (EPMM) working safeguarding family health, and they should the UN Global Strategy for Women’s, Chil- groups. 35 receive support to do so. Evidence shows dren’s and Adolescents’ Health (see data Correspondence to: D Chou [email protected] 43 that women’s groups led by a skilled facilita- ­supplement on bmj.com) are not exhaus- Additional material is published online only. To view tor can improve maternal and neonatal tive but are prioritised based on their sub- please visit the journal online (http://dx.doi. health through participatory learning, partic- stantial effects on the main causes of org/10.1136/bmj.h4255) ularly in rural settings with low access to maternal and newborn mortality and mor- 1 WHO, Unicef, UNFPA, The World Bank, United Nations Population Division. Trends in maternal 36 15 19 health services. Trained community health bidity and stillbirth. mortality: 1990-2013. May 2014. www.who.int/ workers can assist families to strengthen pre- reproductivehealth/publications/monitoring/ maternal-mortality-2013/en/. ventive and caregiving practices and facili- Conclusion 2 UN Inter-agency Group for Child Mortality Estimation. tate appropriate care seeking. Participatory As the agenda of the sustainable develop- Levels and trends in child mortality 2014. 2014. www. mechanisms at every level of the health sys- ment goals emerges, healthy societies where who.int/maternal_child_adolescent/documents/ levels_trends_child_mortality_2014/en/. tem can help foster community engagement women, adolescent girls, newborns, and 3 Cousens S, Blencowe H, Stanton C, et al. National, and ensure that services are transparent, children thrive, and pregnancy and child- regional, and worldwide estimates of stillbirth rates in 2009 with trends since 1995: a systematic analysis. inclusive, and responsive to those they serve. birth are safe everywhere, should be at the Lancet 2011;377:1319-30. Civil society organisations, including parent heart of its ambition. Ending preventable 4 WHO. World Health Statistics 2014. www.who.int/gho/ publications/world_health_statistics/2014/en/. groups, can contribute substantially to social maternal and newborn deaths and stillbirths 5 Kuruvilla S, Schweitzer J, Bishai D, et al. Success factors mobilisation and can hold governments and is possible within a generation and requires for reducing maternal and child mortality. Bull World health services to account for maternal and focused attention on high impact interven- Health Organ 2014;92:533-44B. 6 Unicef, WHO. Every newborn: an action plan to end neonatal health commitments. tions and strategies to improve access and preventable deaths. 2014. www.who.int/maternal_child_ quality of care. Effective care around the adolescent/topics/newborn/enap_consultation/en/. 7 WHO. Strategies toward ending preventable maternal Objective 5—Improve data for decision time of childbirth is most critical for survival mortality (EPMM). 2015. http://who.int/reproductivehealth/ making and accountability and health, but comprehensive strategies topics/maternal_perinatal/epmm/en/. Changing population demographics and dis- and high impact interventions should span 8 The Lancet. Every Newborn. May 2014. www.thelancet. com/series/everynewborn. ease burden affect the epidemiology of risk the continuum of care including before preg- 9 The Lancet. Stillbirth. Apr 2011. www.thelancet.com/ in countries and influence the choice of nancy. The detailed strategic guidance, spe- series/stillbirth. 10 WHO. Newborn health action plan. Resolution strategies to prevent maternal and newborn cific targets, interventions, and milestones WHA67.10. 2014. http://apps.who.int/gb/ebwha/ deaths and stillbirths.23 37 Better data are from the ENAP and EPMM global action pdf_files/WHA67-REC1/A67_2014_REC1-en.pdf. needed for such planning. Establishing plans provide guidance for countries to use 11 Say L, Chou D, Gemmill A, et al. Global causes of maternal death: a WHO systematic analysis. Lancet national registration and vital statistics sys- in their formulation of national health plans Glob Health 2014;2:e323-33. tems in every country is essential for count- and funding priorities. 12 Liu L, Oza S, Hogan D, et al. Global, regional, and national causes of child mortality in 2000-13, with ing births and deaths and tracking Contributors and sources: DC, BD, RJ, MK, and LS wrote projections to inform post-2015 priorities: an updated progress.38 In 2012 only a third of countries this paper on behalf of the ENAP and EPMM writing systematic analysis. Lancet 2015;385:430-40. groups. We gratefully acknowledge contributions from 13 Lawn JE, Blencowe H, Oza S, et al. Every Newborn: had high quality civil registration systems (in alphabetical order): EPMM: Carla Abou Zahr, Agbessi progress, priorities, and potential beyond survival. for maternal or neonatal deaths or still- Amouzou, Isabel Danel, Luc de Bernis, Mengistu Lancet 2014;384:189-205. births; about 137 million births globally, and Hailemariam Damtew, Lynn Freedman, Metin 14 Lawn JE, Blencowe H, Pattinson R, et al. Stillbirths: Gülmezoglu, Rima Jolivet, Marge Koblinsky, Gita Maya Where? When? Why? How to make the data count? nearly all neonatal deaths and stillbirths, Koemarasakti, R Rajat Khosla, Matthews Mathai, Affette Lancet 2011;377:1448-63. were unregistered.13 The countries where McCaw-Binns, Joao Paolo Souza, Annie Portela, Jeffrey 15 Bhutta ZA, Das JK, Bahl R, et al. Can available interventions end preventable deaths in mothers, ­little or no empirical data are available tend Smith, Mary Ellen Stanton, Petra Ten Hoope-Bender, Joshua Vogel, and Mary Nell Wegner. ENAP: Kim Dickson, newborn babies, and stillbirths, and at what cost? to be those where the estimated burden is Joy Lawn, Elizabeth Mason, Lori McDougall, Juana Lancet 2014;384:347-70. highest. Accurate documentation of cause of Willumsen, Severin von Xylander. All authors contributed 16 Ahmed S, Li Q, Liu L, Tsui AO. Maternal deaths averted by contraceptive use: an analysis of 172 countries. to drafting and reviewing the manuscript. DC, BD, LS are death using standard definitions is also criti- Lancet 2012;380:111-25. employees of the World Health Organization. cal to designing effective health programmes 17 Reichenheim ME, Zylbersztajn F, Moraes CL, Lobato G. Competing interests: We have read and understood Severe acute obstetric morbidity (near-miss): a review to tackle preventable causes of mortality. BMJ policy on declaration of interests and have no of the relative use of its diagnostic indicators. Arch Countries must invest in strengthening relevant interests to declare. Gynecol Obstet 2009;280:337-43.

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18 Harrison MS, Ali S, Pasha O, et al. A prospective 26 WHO. The prevention and elimination of disrespect and 36 WHO. WHO recommendation on community population-based study of maternal, fetal, and abuse during facility-based childbirth. 2014. http:// mobilization through facilitated participatory learning neonatal outcomes in the setting of prolonged labor, apps.who.int/iris/bitstream/10665/134588/1/ and action cycles with women’s groups for maternal obstructed labor and failure to progress in low- and WHO_RHR_14.23_eng.pdf?ua=1&ua=1. and newborn health. 2014. www.who.int/maternal_ middle-income countries. Reprod Health 2015; 27 Kassebaum NJ, Bertozzi-Villa A, Coggeshall MS, et al. child_adolescent/documents/community- 12(Suppl 2): S9. Global, regional, and national levels and causes of mobilization-maternal-newborn/en/. 19 WHO, Aga Khan University, PMNCH. Essential maternal mortality during 1990-2013: a systematic 37 Oza S, Lawn JE, Hogan DR, Mathers C, Cousens SN. interventions, commodities and guidelines for analysis for the Global Burden of Disease Study 2013. Neonatal cause-of-death estimates for the early and reproductive, maternal, newborn and child health. Lancet 2014;384:980-1004. late neonatal periods for 194 countries: 2000-2013. 2011. www.who.int/pmnch/knowledge/ 28 WHO. Safe abortion: technical and policy guidance for Bull World Health Organ 2015;93:19-28. publications/201112_essential_interventions/en/. health systems. Second edition. 2012. www.who.int/ 38 Commission on Information and Accountability for 20 WHO. Health systems financing: the path to universal reproductivehealth/publications/unsafe_ Women’s and Children’s Health. Keeping promises, coverage. World health report 2010. www.who.int/ abortion/9789241548434/en/. measuring results. 2011. ­www.who.int/topics/ whr/2010/en/. 29 Sheikh K, Gilson L, Agyepong IA, Hanson K, Ssengooba millennium_development_goals/accountability_ 21 World Bank. Global financing facility in support of every F, Bennett S. Building the field of health policy and commission/Commission_Report_advance_copy. woman every child. Jul 2015. www.worldbank.org/en/ systems research: framing the questions. PLoS Med pdf. topic/health/brief/global-financing-facility-in-support- 2011;8:e1001073. 39 WHO. The WHO application of ICD-10 to deaths during of-every-woman-every-child. 30 UNFPA. The state of the world’s midwifery 2014. http:// pregnancy, childbirth and puerperium: ICD MM. 2012. 22 IEG World Bank, IFC, MIGA. Delivering the millennium unfpa.org/public/home/pid/16021. www.who.int/reproductivehealth/publications/ development goals to reduce maternal and child 31 Tunçalp Ö, Were WM, MacLennan C, et al. Quality of monitoring/9789241548458/en/. mortality. A systematic review of impact evaluation care for pregnant women and newborns-the WHO 40 WHO. Maternal death surveillance and response: technical evidence. 2013. www.oecd.org/derec/norway/ vision. BJOG 2015;122:1045-9. guidance. Information for action to prevent maternal WORLDBANKDeliveringtheMDGtoreducematernaland 32 UNFPA, UNIFEM, OSAGI. Combating gender-based death. 2013. www.who.int/maternal_child_adolescent/ childmortality.pdf. violence: a key to achieving the MDGs. 2005. www. documents/maternal_death_surveillance/en/. 23 Souza JP, Gülmezoglu AM, Vogel J, et al. Moving beyond unfpa.org/publications/combating-gender-based-violence- 41 Mehl G, Labrique A. Prioritizing integrated mHealth essential interventions for reduction of maternal key-achieving-mdgs. strategies for universal health coverage Science mortality (the WHO Multicountry Survey on Maternal 33 WHO. Health systems financing: the path to universal 2014;345:1284-7. and Newborn Health): a cross-sectional study. Lancet coverage. World health report 2010. www.who.int/ 42 Agarwal S, Heltberg R, Diachok M. Scaling up social 381:1747-55. whr/2010/en/. accountability in World Bank operations. 2009. www. 24 Renfrew MJ, McFadden A, Bastos MH, et al. Midwifery 34 Meessen B, Soucat A, Sekabaraga C. Performance- gsdrc.org/go/display&type=Document&id=4062. and quality care: findings from a new evidence- based financing: just a donor fad or a catalyst towards 43 Every Woman Every Child. Shaping the future for informed framework for maternal and newborn care. comprehensive health-care reform? Bull World Health healthy women, children, and adolescents: learn more Lancet 2014;384:1129-45. Organ 2011;89:153-6. about the process to update the global strategy. 2015. 25 Institute of Medicine. Crossing the Quality Chasm: A 35 World Health Organization. WHO recommendations on www.everywomaneverychild.org/global-strategy-2. New Health System for the 21st Century. 2001. http:// health promotion interventions for maternal and iom.nationalacademies.org/Reports/2001/ newborn care. 2015. www.who.int/maternal_child_ Cite this as: BMJ 2015;351:h4255 Crossing-the-Quality-Chasm-A-New-Health-System-for- adolescent/documents/health-promotion- the-21st-Century.aspx. interventions/en/.

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Effective interventions and strategies for improving early child development Investing in early child development is a smart and essential strategy for building human capital, reducing inequities, and promoting sustainable development, argue Bernadette Daelmans and colleagues

he millennium development goal Bowlby in 19513 ; four special scientific jour- Priorities for intervention on child health has led to great nal issues on early child development and Interventions to protect and support early improvements in child survival on efficacy and effectiveness of interventions child development start before conception worldwide. Child mortality has and programmes2-6; the conclusions of the and continue through pregnancy and child- fallen by almost 50%, resulting in Commission on Social Determinants of birth into early childhood (box).14 Protecting anT estimated 17 000 fewer children dying Health7 ; the WHO expert meeting held in children from illness and ensuring adequate every day in 2013 than in 1990.1 Neverthe- January 2013 to review evidence on the role nutrition are essential but not sufficient. less, many children who survive do not of the health sector in improving early child Children need to grow in a caring, safe, and thrive, with over 200 million children under development8; and empirical neuroscience stimulating environment that provides 5 years of age at risk of not attaining their research linking early experiences with opportunities for ongoing learning and mas- developmental potential.2 Physical and men- health and diseases across the lifespan. tery. We highlight three areas of intervention tal health, educational and occupational that can be integrated into ongoing pro- attainment, family wellbeing, and the capac- Why early development is important grammes for maternal and child healthcare ity for mutually rewarding social relation- Child development refers to the expansion of and nutrition: promotion of responsive and ships all have their roots in early childhood. physical, cognitive, psychological, and nurturing caregiving, supporting maternal We now have a good understanding of the socioemotional skills that lead to increased mental health, and social protection serious implications of young children going competence, autonomy, and independence. through poverty reduction strategies that off course, including the longer term eco- What children experience during the early strengthen family capacity to provide for nomic and societal ramifications. Here, we years (prenatal to the age of 5 years) creates children. synthesise evidence about effective interven- a trajectory across the lifespan. Adverse The benefits of these interventions include tions and strategies to improve early child exposures and experiences in early child- better mental and physical health and aca- development, and call for it to be included in hood increase the risk of poor social, cogni- demic performance during childhood and a new global strategy on women’s, chil- tive, and health outcomes, including adolescence, and increased economic pro- dren’s, and adolescents’ health. economic dependency, violence, crime, sub- ductivity and social integration during adult- stance misuse, and adult onset of non-com- hood.15 16 The rate of return on investment in Methods municable diseases. Early deficits are programmes that promote early childhood Our analysis draws on the following evi- compounded and become increasingly diffi- for disadvantaged children is estimated to be dence: WHO records on early child develop- cult to reverse beyond early childhood.9 7-10%.17 ment, beginning with the Commission on Genes and experiences interact to shape Maternal Care and Mental Health led by John brain architecture and functioning, which Promoting responsive and nurturing care develops rapidly in the first few years of life Children thrive in stable and engaged family when neuroplasticity is greatest. Neural con- environments in which parents show inter- Key messages nections formed early in life lay the founda- est and encourage children’s development Adverse exposures and experiences in tions for physical and mental health, and learning. WHO and Unicef developed early childhood increase risks for poor affecting adaptability, learning capacity, lon- Care for Child Development (CCD), an evi- 10 social, cognitive, and health outcomes gevity, and resilience. Supporting chil- dence based intervention to support care dren’s development is therefore imperative, giving.18 By promoting age appropriate play Despite great strides in improving child especially for the millions of children who and communication, CCD enables carers to survival over 200 million children under 5 are at risk of not reaching their full live in disadvantaged and vulnerable fami- strengthen their sensitivity and responsive- potential lies and communities and who face multiple ness to their child’s needs. Responsive care adversities. giving in turn has an effect on care practices, Interventions implemented through The figure summarises the risk factors for including responsive feeding, seeking care health, nutrition, education, and social suboptimal development. They include biolog- for illness, child stimulation, and opportuni- protection sectors are effective at 11 improving early child development ical and contextual factors. Gender dispari- ties for learning, and it also benefits parental ties, for example, are a critical component of mental health.19 CCD has been shown to Such interventions have long term health, the sustainable development framework and improve children’s cognitive, social, and lan- economic, and social benefits start prenatally, with boys being more sensitive guage scores.20 Landmark programmes, Interventions to promote nurturing care, to neurological threats12 while girls are more at such the Jamaican home stimulation pro- protect maternal mental health, and risk from selective abortion.13 To prevent and gramme, have shown the immediate and reduce poverty should be prioritised to mitigate risks, integrated responses are long term effects of the intervention when complement and enhance services for required that improve children’s physical, delivered as part of health and nutrition maternal and child health and nutrition familial, and societal environments. ­services.21

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CCD can be integrated into services for Essential interventions to support early child development well and sick children, preschool pro- Preconception care grammes, and services to prevent and man- • Promotion of adequate maternal nutrition age maltreatment.22 23 Work is in progress to • Maternal immunisation develop complementary tools that enable • Birth spacing providers to recognise when children show a • Cessation of smoking and substance misuse developmental delay or disability and to act • Detection of genetic conditions appropriately, with intensified­ intervention • Prevention from environmental toxins or referral.24 This addition is expected to • Prevention of intimate partner violence improve the capacity of countries to care for • Support for mental health children with disabilities and implement Maternal health rehabilitative strategies.25 • Antenatal, childbirth, and postnatal care by a skilled provider • Detection and care for maternal mental health problems Supporting maternal mental health Child health Starting with Bowlby’s seminal work on 3 • Immunisation attachment and loss, evidence has accumu- • Prevention and integrated management of newborn conditions lated about the adverse effects of maternal • Prevention and integrated management of childhood illnesses depressive symptoms on early child develop- • Counselling on Care for Child Development ment and quality of parenting. Between a Nutrition third and a fifth of pregnant women and mothers of newborns experience serious • Counselling on infant and young child feeding, management of feeding difficulties, and inadequate growth mental health problems that can be rec- ognised through use of simple reliable • Counselling on Care for Child Development tools.26 Poor maternal mental health none- Adolescent health theless remains a seriously under-rec- • Promoting health literacy and support for healthy lifestyles ognised public health problem. Young • Addressing adolescent health needs and agency for decision making to promote health and children can be protected against ill effects if development mothers are helped to improve their caregiv- Violence prevention ing skills and treated for their underlying • Prevention of child maltreatment conditions, as needed.27 These interventions • Prevention of violence in the home and community can be integrated into health services and Environmental health implemented by paraprofessionals through • Access to safe water, sanitation, and hygiene home visiting, mothers’ groups, or by com- • Access to electricity munity health workers with specialised • Safe places for play training. • Prevention of exposure to toxins such as lead, mercury, and pesticides • Prevention of indoor and outdoor air pollution Family support through social protection Social protection to reduce poverty • Social help and cash transfer schemes Poverty remains a pervasive determinant of • Birth registration suboptimal health and development. Chil- • Parental leave and child care dren growing up in poverty have an • Child protection services increased likelihood of being exposed to environmental risks, household stresses, and violence; they also receive less optimal Biological Contextual healthcare, nutrition, and education. Evi- Parents risk factors Birth Depression and ill health, low risk factors dence from countries that have implemented Preterm birth, education, high levels of stress birth complications large scale early child development pro- Child conditions grammes shows the importance of coordi- Insensitive or non-responsive care Intrauterine factors giving; child maltreatment, including physical nated actions providing social protection Maternal nutrition, maternal Environmental punishment; being orphaned; refugee status (such as financial support); building par- infections, maternal substance exposures use, intrauterine growth restriction through life course: Family ents’ capacities (vocational training, parent- Heavy metals Inadequate opportunities for learning in (lead and mercury), the home, crowded or highly chaotic home ing skills, etc), and using multiple platforms environmental toxins environments, caregiver alcohol and to reach families and children with effective (arsenic, endocrine substance misuse, economic constraints, Child nutrition disruptors, pesticides, poverty, exposure to violence, interventions for health, nutrition, child Suboptimal breast feeding, protein polychlorinated including intimate partner violence care, and learning.28 calorie malnutrition, micronutrient biphenyls), Community de­ciencies (iodine de­ciency, household air Conditional cash transfer (CCT) pro- iron de­ciency, zinc de­ciency) pollution Community violence, poor quality early care environments outside the grammes, implemented particularly in Latin home, lack of health and social services, limited or no access to nutritious food, America, and unconditional cash transfer lack of access to sanitation or safe Childhood infections programmes in sub-Saharan Africa have drinking water, societal stigmatisation Parasitic infections, HIV infection, of children with developmental been shown to benefit nutrition and child malaria, chronic diarrhoea disabilities development, helping to break the intergen- erational effects of poverty.29 30 By increas- ing household resources and access to early Factors compromising early child development child care and preprimary education, such

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programmes can substantially boost chil- every child has support to reach their devel- Tarun Dua medical officer12 dren’s learning and development. opmental potential. Innovations that pro- Raschida R Bouhouch technical officer1 mote healthy development in the first five Zulfiqar A Bhutta director13, 14 Moving forward years are showing the long term effect of Gary L Darmstadt associate dean for maternal and child health professor of neonatal and developmental Implementation of interventions to optimise early life interventions on physical, cogni- pediatrics15 child development need guidance and polit- tive, and socioemotional development. They Nirmala Rao professor of early childhood development ical will to promote coordinated governance, include mobile and internet based technolo- and education16 increased funding and capacity, and gies to transfer information, financial assis- 1Department of Maternal, Newborn, Child, and improved data collection to inform pro- tance, and provision of home-based Adolescent Health, World Health Organization, 1211 Geneva 27, Switzerland gramme improvements and show that they counselling and support by community 2 34 Department of Pediatrics, University of Maryland School work. workers. of Medicine, Baltimore, Maryland, USA Coordinated governance—Leadership 3Bernard van Leer Foundation, The Hague, Netherlands across sectors is needed at national, subna- Conclusions 4New York, USA tional, and local levels to implement coordi- The new sustainable development goals 5DST_NRF Centre of Excellence in Human Development, nated interventions for young children and adopted by the United Nations launch an Durban, South Africa families. Coordinated governance must exciting period in the global effort to end 6Human Sciences Research Council, Durban, South Africa bring together health, nutrition, environ- poverty, transform the world to better meet 7Grand Challenges Canada, Toronto, Canada ment, education, and child and social pro- human needs, and protect the environment 8United Nations Children’s Fund, New York, USA tection, as well as the public and private to ensure peace and realise human rights. As 9Department of Applied Psychology, NYU Steinhardt, sectors and civil society.31 the recent secretary general report empha- New York, USA Financing—Early childhood programmes sises, “Millions of people, particularly 10Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, CT, USA and systems of support have been seriously women and children, have been left behind 11Departments of Psychiatry and Behavioural underfunded. The establishment of coordi- in the unfinished work of the MDGs [millen- Neurosciences and Pediatrics, McMaster University, nated early childhood plans should be a call nium development goals].”35 The new Hamilton, ON, Canada to action to bilateral and multilateral agen- agenda can transform the way health and 12Department of Mental Health and Substance Abuse, cies, national governments, and the private human services are delivered and create the World Health Organization, Geneva, Switzerland sector to dedicate increased funding through conditions globally so children can have 13Center for Global Child Health, Hospital for Sick Children, Toronto, Canada traditional and innovative financial instru- equitable opportunities to meet their devel- 14 32 Center of Excellence in Women and Child Health, Aga ments. Investment is also needed across opmental potential and grow into healthy Khan University, Karachi, Pakistan multiple sectors to strengthen the capacity of and socially integrated citizens. This historic 15Department of Pediatrics, Stanford University School of the workforce, assure quality of services, moment calls for a bold commitment to sup- Medicine, Stanford, CA, USA and provide administrative oversight and port healthy child development as the foun- 16Faculty of Education, University of Hong Kong, China accountability. Using multiple delivery plat- dation for sustainable societies. On behalf of the steering committee of a new scientific forms, such as community health workers, We thank Mark Tomlinson for a careful review of the draft series on early child development. primary healthcare services, preschool edu- manuscript. Correspondence to: B Daelmans [email protected] cation, and parent groups, is necessary to Contributors and sources: This manuscript was developed 1 WHO. Global health observatory. 2014. www.who. as a background document to inform the content of a new int/gho/child_health/mortality/mortality_under_ ensure success. Global Strategy for Women’s, Children’s and Adolescents’ five_text/en/. Improved measurement, research, and Health. The authors are members of the Steering Team on 2 Grantham-McGregor S, Cheung YB, Cueto S, et al. Developmental potential in the first 5 years for innovation—UN agencies are working Early Child Development that is synthesising state-of-the art evidence on the burden of sub-optimal development, children in developing countries. Lancet together to develop and align new measures effective interventions, and programming at scale for early 2007;369:60-70. to track child development and monitor the child development. BD coordinated the overall preparation 3 Bowlby J. Maternal care and mental health. Bull World Health Organ 1951;3:355-533. of the manuscript. BD, MB, JL, JL, LR and KS prepared the quality of services and to use the results of 4 Walker SP, Wachs TD, Grantham-McGregor S, et al. first draft of the manuscript. All authors reviewed and evaluation to consolidate, extend, and Inequality in early childhood: risk and protective contributed to the finalisation of the manuscript. factors for early child development. Lancet improve programmes. New investments, Competing interests: We have read and understood 2011;378:1325-38. methodological advancements, and political BMJ policy on declaration of interests and have no 5 Black MM, Dewey KG. Promoting equity through will are needed to validate these emerging relevant interests to declare. integrated early child development and nutrition interventions. Ann N Y Acad Sci 2014;1308:1-10. measures, integrate them into existing data The authors alone are responsible for the views 6 Britto PR, Engle PL, Super CM. Handbook of early expressed in this article, which does not necessarily collection efforts, and help build manage- childhood development research and its impact on represent the views, decisions, or policies of WHO or the global policy. Oxford University Press, 2013. ment information systems that will generate institutions with which the authors are affiliated. 7 Irwin LG, Siddiqi A, Hertzman C. Early child development: data to guide policy. Although measurement Provenance and peer review: Not commissioned; a powerful equalizer. Final report to the WHO Commission externally peer reviewed. on Social Determinants of Health. WHO, 2007. has been a challenging issue in advancing 8 WHO. Meeting report: nurturing human capital along early child development, there is now a Bernadette Daelmans coordinator of policy, planning, the life course: investing in early child development. 1 selection of tools for assessing preschool and programmes WHO, 2013. Maureen M Black endowed professor of pediatrics2 9 Shonkoff JP, Phillips DA. From neurons to children, including the Inter-American neighborhoods: the science of early childhood 3 Development Bank’s Regional Project on Joan Lombardi senior adviser development. ERIC, 2000. Jane Lucas consultant in early child development4 10 Shonkoff JP, Richter L. The powerful reach of early Child Development Indicators (PRIDI), the childhood development: a science-based foundation Linda Richter director distinguished research fellow5, 6 Early Development Instrument (EDI), and for sound investment. In: Handbook of early childhood 7 Save the Children’s International Develop- Karlee Silver vice president programmes development research and its impact on global policy. Pia Britto chief of early child development8 Oxford University Press, 2013:24-34. ment and Early Learning Assessment 11 Wachs TD, Rahman A. The impact of risk and protective (IDELA); scales are also emerging for chil- Hirokazu Yoshikawa professor of globalization and influences on children’s development in low income education9 countries. In: Handbook of early childhood dren under 2 years old.33 Rafael Perez-Escamilla professor of epidemiology and development research and its impact on global policy. Scientific, technological, social, and busi- public health10 Oxford University Press, 2013:85-122. ness innovation can ensure that the largest 12 Kent AL, Wright IM, Abdel-Latif ME. Mortality and Harriet MacMillan professor of psychiatry and adverse neurologic outcomes are greater in preterm numbers of children are reached and that behavioural neurosciences11 male infants. Pediatrics 2012;129:124-31.

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13 Richards E, Theobald S, George A, et al. Going beyond the 21 Grantham-McGregor SM, Powell CA, Walker SP, 29 Garcia M, Moore CG, Moore CM. The cash dividend: the surface: gendered intra-household bargaining as a social Himes JH. Nutritional supplementation, rise of cash transfer programs in sub-Saharan Africa: determinant of child health and nutrition in low and psychosocial stimulation, and mental development World Bank, 2012 middle income countries. Soc Sci Med 2013;95:24-33. of stunted children: the Jamaican Study. Lancet 30 Fernald LC, Gertler PJ, Neufeld LM. Role of cash in 14 Denboba AD, Sayre RK, Wodon QT, Elder LK, Rawlings 1991;338:1-5. conditional cash transfer programmes for child health, LB, Lombardi J. Stepping up early childhood 22 Sandler I, Schoenfelder E, Wolchik S, MacKinnon D. growth, and development: an analysis of Mexico’s development: investing in young children for high Long term impact of prevention programs to promote Oportunidades. Lancet 2008;371:828-37. returns. World Bank, 2014. effective parenting: lasting effects but uncertain 31 Britto PR, Yoshikawa H, van Ravens J, et al. 15 Gertler P, Heckman J, Pinto R, et al. Labor market processes. Annu Rev Psychol 2011;62:299-329. Strengthening systems for integrated early returns to an early childhood stimulation intervention 23 Mikton C, Butchart A. Child maltreatment prevention: a childhood development services: a cross-national in Jamaica. Science 2014;344:998-1001. systematic review of reviews. Bull World Health Organ analysis of governance. Ann N Y Acad Sci 16 Grantham-McGregor SM, Fernald LC, Kagawa RM, 2009;87:353-61. 2014;1308:245-55. Walker S. Effects of integrated child development and 24 Ertem I. Developmental difficulties in early childhood: 32 UN Sustainable Development Solutions Network. Key nutrition interventions on child development and prevention, early identification, assessment and elements for a successful Addis Ababa Accord on nutritional status. Ann N Y Acad Sci 2014;1308:11-32. intervention in low- and middle-income countries: a financing for sustainable development. UN, 2015. 17 Heckman J. Four big benefits of investing in early review. WHO, 2012. 33 Khan NZ, Muslima H, Shilpi AB, et al. Validation of a childhood development. 2015. http:// 25 Yousafzai AK, Lynch P, Gladstone M. Moving beyond home-based neurodevelopmental screening tool for heckmanequation.org/content/ prevalence studies: screening and interventions for under 2-year-old children in Bangladesh. Child Care resource/4-big-benefits-investing-early-childhood- children with disabilities in low-income and Health Dev 2013;39:643-50. development. middle-income countries. Arch Dis Child 34 Pallas SW, Minhas D, Pérez-Escamilla R, et al. 18 WHO, Unicef. Care for child development. 2012. www. 2014;99:840-8. Community health workers in low- and middle- who.int/maternal_child_adolescent/documents/ 26 WHO. Maternal mental health and child health and income countries: what do we know about scaling up care_child_development/en/. development in low and middle income countries: and sustainability? Am J Public Health 19 Yousafzai AK, Rasheed MA, Rizvi A, Armstrong R, Bhutta report of the meeting, WHO, 2008. 2013;103:e74-82. ZA. Effect of integrated responsive stimulation and 27 Rahman A, Malik A, Sikander S, Roberts C, Creed F. 35 Moon B. The road to dignity by 2030: ending poverty, nutrition interventions in the lady health worker Cognitive behaviour therapy-based intervention by transforming all lives and protecting the planet. programme in Pakistan on child development, growth, community health workers for mothers with depression Synthesis report of the secretary-general on the and health outcomes: a cluster randomised factorial and their infants in rural Pakistan: a cluster-randomised post-2015 sustainable development agenda. UN, effectiveness trial. Lancet 2014;384:1282-93. controlled trial. Lancet 2008;372:902-9. 2014. 20 Jin X, Sun Y, Jiang F, et al. Care for development 28 Jayaratne K, Kelaher M, Dunt D. Child health partnerships: intervention in rural China: a prospective follow-up a review of program characteristics, outcomes and their study. J Dev Behav Pediatr 2007;28:123-8. relationship. BMC Health Serv Res 2010;10:172. Cite this as: BMJ 2015;351:h4029

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Nutrition and health in women, children, and adolescent girls Urgent action is needed to tackle malnutrition in all forms and to help nutrition unlock the potential of investment in the health of women, children, and adolescents, say Francesco Branca and colleagues

very year the lives of around 50 mil- Methods mal breast feeding, stunting, wasting, and lion children are put at risk because This paper highlights nutrition related prior- deficiencies of vitamin A and zinc). In 2013 they are dangerously thin from ity actions to improve the health of women, the growth of around 161 million children acute undernutrition, while the children, and adolescent girls. It is based on aged under 5 was stunted by chronic under- long term health of more than 40 existing policy guidance issued by the World nutrition, leading to hampered cognitive and Emillion children is threatened because they Health Assembly in the form of resolutions physical development, poor health, and an are overweight. Two billion people suffer or targets; guidelines from the World Health increased risk of degenerative diseases.3 In from vitamin and mineral deficiencies, but Organization; or the outcome documents of the same year 51 million children were overweight and obesity are key contributors the Second International Conference on wasted (having low weight for height) to the non-communicable diseases that Nutrition (ICN2). because of acute undernutrition; severe account for almost two thirds (63%) of adult The vast majority of the recommended wasting increases the risk of morbidity, par- deaths globally. These different forms of mal- actions proposed in this paper were agreed ticularly from infectious diseases such as nutrition—undernutrition, overweight and by the 162 member states attending the ICN2 diarrhoea, pneumonia, and measles, and is obesity, and micronutrient deficiencies— in Rome in November 2014.1 These recom- responsible for as many as two million now affect people across the same communi- mendations were developed by the secretar- deaths a year.4 ties and harm people of all ages. (Unless iats of the Food and Agriculture Organization Meanwhile, deficiencies of vitamin A and otherwise cited, the figures given are WHO of the United Nations and WHO on the basis zinc cause many deaths (157 000 and 116 000 estimates.) of current ­evidence and were subject to child deaths, respectively, in 2011),5 and Improving nutrition therefore presents a extensive consultation. An information note iodine and iron deficiencies, along with key opportunity to improve health. As the on the ICN2 provides more background infor- stunting, contribute to children not achiev- UN secretary general launches his second mation on the recommended actions.2 ing their full potential. Iron and calcium Global Strategy for Women’s, Children’s and Some additional recommendations, spe- deficiencies increase the risks associated Adolescents’ Health in September 2015 a cific to women’s, children’s, or adolescents’ with pregnancy, particularly maternal mor- strengthened focus on nutrition is war- nutrition, are based on WHO guidance. tality.5 ranted, with special attention to the first Where such a recommendation does not At the same time overweight and obesity 1000 days of life (from pregnancy to the exist, emerging evidence reviewed by the in children and adults have been increasing child’s second birthday), pregnant and lac- authors is cited. rapidly in all regions of the world, and half a tating women, women of reproductive age, billion adults were affected by obesity in and adolescent girls. Problems associated with poor nutrition 2010. Dietary risk factors, together with Good nutrition is fundamental for optimal ­inadequate physical activity, were responsi- health and growth. Through its effect on ble for 10% of the global burden of disease health and cognitive development it is also and disability in 2010.6 Key messages vital for academic performance and produc- tivity, and therefore for healthy economies Socioeconomic impact of malnutrition Investment in nutrition is crucial to future and socioeconomic development. Malnutrition contributes to an estimated 200 efforts to improve the health of women, million children failing to attain their full children, and adolescents; the potential Health effects of malnutrition development potential. Stunting is esti- human, societal, and economic gains from The consequences of malnutrition could mated to reduce a country’s gross domestic such investment are substantial. hardly be more serious: around 45% of child product by as much as 3%,7 and eliminating Clear global commitments to action are deaths in 2011 were due to malnutrition anaemia could increase adult productivity in place, backed by targets to measure (including fetal growth restriction, subopti- by 5-17%.8 progress. All contributors, across government and society, must come Box : Nutrition in recent global initiatives and commitments together to turn these commitments into action. • Global Strategy for Women’s and Children’s Health: the UN secretary general’s strategy, put into action by the global Every Woman Every Child movement, clearly set out the need to tackle nutrition in young Specific actions are needed to improve the children.11 quality of the diet; to protect, promote, • Global nutrition targets for 2025: countries are working towards six global targets agreed at the 65th and support breast feeding; to ensure that World Health Assembly in 2012 (table 1). everyone has access to essential nutrition • Global Action Plan for the Prevention and Control of Non-communicable Diseases 2013-20: includes actions; to provide adequate water and targets to reduce salt intake by a third and to halt the increase in obesity among adolescents and adults. sanitation; and to provide information and • Second International Conference on Nutrition: in November 2014 the world’s leaders committed to education. eradicating hunger and preventing all forms of malnutrition worldwide.12

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Box : What do we mean by malnutrition? • Malnutrition: nutritional disorders in all of their forms (including imbalances in energy intake, macronutrient and micronutrient deficiencies, and unhealthy dietary patterns). Conventionally, the emphasis has been on inadequacy, but malnutrition also applies to excess and imbalanced intakes. • Overweight: a situation caused by an excessive, unbalanced intake of energy or nutritional substances (and often combined with a sedentary lifestyle). • Stunting: low height for age (more than two standard deviations below the WHO child growth standard median for children under 5). Stunting is defined by WHO as a public health problem when 20% or more of the population are affected. • Undernutrition: a situation in which the body’s energy and nutrient requirements are not met because of under-consumption or the impaired absorption and use of nutrients. Undernutrition commonly refers to a deficit in energy intake, but it can also refer to deficiencies of macronutrients and micronutrients, and it can be either acute or chronic. • Wasting: low weight for height (more than two standard deviations below the WHO child growth standard median for children under 5). Wasting becomes a public health problem when 5% or more of the population are affected.

Every $1 (£0.64; €0.91) invested in tackling along with unsustainable production and stunted and to have a higher risk of morbid- undernutrition is estimated to yield around consumption patterns, food losses and ity and mortality and of developing $18 in return—the median benefit:cost ratio waste, and unequal distribution and access. non-communicable diseases later in life. from a study modelling the effect of prevent- Malnutrition is often aggravated by poor Conversely, if the mother is obese when she ing one third of stunting in children up to feeding and care practices for infants and starts her pregnancy she is also at increased age 3 in 17 high burden countries. 9 More spe- young children, as well as poor sanitation risk of complications during pregnancy or cifically, a recent study of the benefit:cost and hygiene. A lack of access to education, delivery, which could result in premature ratio of a package of nutrition interventions quality health systems, and safe drinking delivery—and, therefore, a low birth weight aimed at averting stunting in 15 countries water can also have a negative effect, along for her baby. Alternatively, if she carries the found that benefits outweighed costs by as with infectious disease and the ingestion of baby to full term, her baby is more likely to much as 42:1, depending on the existing eco- harmful contaminants. have a higher birth weight and a higher risk nomic and nutritional situation.10 In recent years progress has been made in of child and adolescent obesity. developing knowledge and understanding The past two decades have also seen a What progress has been made in tackling of the magnitude and scope of nutritional major shift in understanding of the policy malnutrition? challenges, the increasing contribution of responses required to improve nutrition and Better understanding of the challenges non-communicable diseases, and the promote healthy diets. It is now clear that an and solutions ­complex web of factors that can influence enabling environment plays a key role and The root causes of malnutrition and the fac- ­nutrition. that policies that change aspects of the food tors leading to it are complex and multidi- A greater understanding has developed environment are required (such as what foods mensional. Poverty, underdevelopment, and regarding the importance of nutrition at dif- are available, what levels of fat, sugar, or salt low socioeconomic status are major contrib- ferent stages of the life course and the effect they contain, or how much they cost), as well utors, along with other social determinants. of poor nutrition across generations (fig 1). as nutrition education and information. Current food systems struggle to provide An intergenerational cycle of malnutrition Similarly, there is now much greater adequate, safe, and diversified foods. The exists whereby a woman who has anaemia, awareness that effective responses need to reasons include constraints on access to for example, is likely to have a baby with a come from beyond the health sector and that land, water, and other resources—often reduced birth weight. Low birthweight this must involve other sectors, such as those aggravated by environmental damage— babies are more likely to be wasted or related to water and sanitation, education, trade, and social protection. Crucially, a rad- Low birth weight and ical transformation is needed so that food compromised body composition systems can ensure that everyone has access Impaired mental to a sustainable, balanced, and healthy diet. development Higher mortality rate Inappropriate feeding practices Progress towards global nutrition targets Frequent infections Reduced Fetal and infant Significant progress has been made in reduc- malnutrition Societal and capacity for care Inappropriate food, environmental Inadequate health and care (including ing hunger and undernutrition in the past untimely/inappropriate factors Rapid catch-up two decades: the percentage of people in growth complementary feeding) Elderly growth developing regions experiencing hunger fell malnutrition Child malnutrition from 24% in 1990-92 to 14% in 2011-13.14 The Obesity, Reduced intellectual abdominal obesity, potential and reduced 2014 Global Nutrition Report showed, how- Inadequate diabetes, fetal cardiovascular school performance ever, that the world is not on track to meet nutrition disease Inappropriate food, Inappropriate food, any of the six World Health Assembly nutri- health and care health and care Adult tion targets (table 1). malnutrition Adolescent malnutrition Pregnancy What are the priorities for improving low weight Reduced intellectual nutrition? gain potential and reduced Inappropriate food, school performance Improving women’s, children’s, and adoles- health and care Higher maternal cents’ nutrition requires a range of policies, mortality programmes, and interventions at different stages of life. And, since we know that mal- Fig 1 | Nutrition through the life course—proposed causal links13 Reproduced from WHO childhood overweight policy brief, based on figure fromD arnton-Hill I, nourished women give birth to malnour- Nishida C, James WPT. A life course approach to diet, nutrition and the prevention of chronic ished children, it is possible to take action to diseases. Public Health Nutr 2004;7:101-21. improve nutrition across generations (fig 2 ).

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Table 1 | Findings of the 2014 Global Nutrition Report17 Baseline Baseline Globally Category WHA target years status Target for 2025 on course? Comments Stunting 40% reduction in number of children under 5 2012 162 million ~100 million No Current pace projects 130 million by who are stunted* (~15% prevalence) 2025 (20% reduction) Anaemia 50% reduction of anaemia in women of 2011 29% 15% No Very little movement (was 32% in 2000) reproductive age Low birth weight 30% reduction in low birth weight 2008-12 15% 10% No Little progress to date Under 5 overweight No increase in childhood overweight 2012 7% 7% No Upward trajectory is unchecked Under 5 overweight Increase the rate of exclusive breast feeding in 2008-12 38% 50% No Rate was 37% in 2000, 41% in 2012 first six months to at least 50% Wasting Reduce and maintain childhood wasting to 2012 8% <5% No No progress (was 8% globally in 2013) under 5%

Table 2 | Recommended actions to improve adolescents’ nutrition Recommendations and actions Who needs to take action? Improve maternal nutrition and health Establish policies and strengthen interventions to ensure that pregnant and National policy makers, health service providers lactating adolescent mothers are adequately nourished Introduce measures to prevent adolescent pregnancy and to encourage pregnancy National policy makers, health service providers, education sector spacing Prevent and control anaemia Promote healthy and diversified diets containing adequate amounts of bioavailable National policy makers, food and agriculture sectors, health and education sectors iron Promote consumption of nutrient dense foods, especially foods rich in iron National policy makers, health and education, food and agriculture sectors Where necessary, implement supplementation strategies and consider fortification National policy makers, food and agriculture sectors of wheat and maize flours with iron, folic acid, and other micronutrients in settings where these foods are major staples Prevent and treat malaria in pregnant women as part of strategies to prevent and control anaemia Ensure universal access to and use of insecticide treated nets National policy makers, health service providers, development partners Provide preventive malaria treatment for pregnant women in areas with moderate to National policy makers, health service providers high malaria transmission Offer a healthy diet to all populations Create coherence in national policies and investment plans, including trade, food, Regional and national policy makers, food and beverage industries, creative and and agricultural policies, to promote a healthy diet and protect public health18* media industries Encourage consumer demand for healthy foods and meals* Promote physical activity in adolescents Create a conducive environment that promotes physical activity to tackle sedentary Regional, national, and local policy makers, urban planners, early years education, lifestyle19† health services Promote optimal nutrition in adolescents with HIV/AIDS Provide nutrition counselling to improve health outcomes in adolescents with HIV20‡ Health service providers, development partners All recommended actions are based on those proposed in the Framework for Action issued by the Second International Conference on Nutrition in November 2014 except (*), which is based on a WHO healthy diet fact sheet; (†), which is based on WHO guidelines on physical activity; and (‡), for which evidence is available but no formal WHO recommendation.

Specific recommendations and actions to help put them into practice are shown in Immediate initiation of breast feeding tables 2 to 4. Exclusive breast feeding to  months Diet and micronutrients during pregnancy Actions to improve adolescent girls’

Adequate complementary nutrition Diet and micronutrients feeding from  months Adolescent girls should be at the heart of a during ageing life course approach—a young adolescent Birth  days girl is still a child, but often she will soon become a mother. Adolescent pregnancy is Pre-pregnancy dietary  days advice for adolescent associated with higher risk of maternal mor- girls and women ­ year Continued breast feeding tality and morbidity, stillbirths, neonatal deaths, preterm births, and low birth weight. ‚ years In addition to actions to prevent adolescent € years pregnancy and encourage pregnancy spac- Adolescent dietary ­‚ years Energy and nutrient advice adequate diet ing, efforts are required to ensure that preg- nant and lactating teenage mothers are

Micronutrient adequately nourished. supplementation as necessary School meals Actions to improve child nutrition The first 1000 days of life (from pregnancy to Fig 2 | Improving nutrition throughout the life course15 the child’s second birthday) present an

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Table 3 | Recommended actions to improve child nutrition Recommendations and recommended concrete actions Who needs to take action? Promote optimal infant and young child feeding* Adapt and implement the International Code of Marketing of Breast Milk Substitutes National policy makers and subsequent relevant World Health Assembly resolutions Ensure that health services and employment policies promote, protect, and support National policy makers, employers, health facilities breast feeding, including WHO’s Baby-Friendly Hospital Initiative Encourage and promote active participation of men in sharing care for infants and National policy makers, educational institutions, employers, health facilities young children Empower women and enhance their health and nutritional status throughout the life National policy makers, educational institutions, employers, health facilities course Ensure that policies and practices in emergency situations and humanitarian crises International organisations, national policy makers, humanitarian actors promote, protect, and support breast feeding Tackle maternal exposure to the availability and marketing of complementary foods International organisations, national policy makers, humanitarian actors Improve supplementary feeding programmes for infants and young children International organisations, national policy makers, humanitarian actors Improve coverage of treatment for wasting Adopt policies and actions and mobilise funding to improve coverage using the National policy makers, development partners, humanitarian actors, health services community based management of acute malnutrition approach Improve the integrated management of childhood illnesses National policy makers, health services Reduce the risk of anaemia in children Provide iron supplementation for pre-school children National policy makers, health services Reduce prevalence and severity of infectious disease in children Provide zinc supplementation to reduce the duration and severity of diarrhoea and National policy makers, health services to prevent subsequent episodes in children Implement policies and programmes to ensure universal access to and use of National policy makers, health services insecticide treated nets Provide periodic deworming for all school age children in endemic areas National policy makers, health services, schools Improve the management of moderate acute malnutrition in children Provide supplementary foods for the management of moderate acute malnutrition National policy makers, health services, development partners, humanitarian actors in children† Reduce children’s intakes of free sugars and sodium Regulate the marketing of food and non-alcoholic beverages to children in National policy makers, food industry, advertising and media sector accordance with WHO recommendations Provide adequate food in school settings Promote physical activity in children Create a conducive environment that promotes physical activity and tackles National and local policy makers, urban planners, early years education services, sedentary lifestyle health services *Exclusive breast feeding up to age 6 months, followed by adequate complementary feeding (from 6 to 24 months) and continued breast feeding up to 2 years of age or beyond. All recommended actions are based on those proposed in the Framework for Action issued by the Second International Conference on Nutrition in November 2014 except (†), which is based on a WHO Technical Note (www.who.int/nutrition/publications/moderate_malnutrition/9789241504423/en/).

important window of opportunity to improve and control over, social protection and nutrition is needed now. We know what child nutrition. The key pillar of any strategy resources such as income, land, water, and needs to be done—as explained by the rec- to improve this—in addition to good mater- technology. Direct multisectoral actions to ommended actions in tables 2 to 4 —and the nal nutrition and health—is optimal feeding tackle critical women’s nutritional chal- clear global commitments to action. and care for infants and young children. lenges, such as iron deficiency anaemia, We now need to implement these commit- Exclusive breast feeding (defined as the need to be rolled out on a larger scale to ments and ensure the resources to do so (the practice of giving an infant only breast milk achieve universal coverage. Addis Ababa Action Agenda refers to the need for the first six months of life, with no other to scale up efforts to end hunger and malnu- food or water), in particular, has the single Improving nutrition across the life course trition at paragraph 13 and the need to largest potential effect on child mortality of These targeted recommendations must be strengthen national health systems at para- any preventive intervention. Timely and ade- supported by a raft of nutrition interventions graph 77).16 In a nutshell, actions are needed quate complementary feeding, with particu- throughout the life course (see the ICN2 to improve the quality of diets; protect, pro- lar attention to vitamin and mineral content Framework for Action for the full range of mote, and support breast feeding; ensure that and the nutrient density of foods, is urgently recommended actions). Policies are needed, everyone has access to essential nutrition needed. for example, to transform food systems and actions; provide adequate water and sanita- strengthen health systems. Universal access tion; and provide information and education. Actions to improve women’s nutrition to functioning and resilient health systems To achieve these aims governments and The health and nutrition statuses of women and the scaled-up delivery of interventions society must join forces and make nutrition a and children are intimately linked. Improv- can improve nutrition. Governments and priority. Governments, health services, the ing the health of women and children, there- international organisations also have a role food and agriculture industries, schools and fore, begins with ensuring the health and in developing clear guidelines on healthy universities, and community leaders—along nutritional status of women throughout all diets. with many others—must work together in a stages of life, and it continues with women coordinated and coherent way. being providers for their children and fami- What needs to happen now? The potential human, societal, and eco- lies. Thus, a key priority is female empower- If we want to improve the health of women, nomic gains from turning these commitments ment and women’s full and equal access to, children, and adolescents, action to invest in into action are substantial, and the costs of

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Table 4 | Recommended actions to improve women’s nutrition Recommended actions and evidence Who needs to take action? Prevent and control anaemia Promote consumption of nutrient dense foods, especially foods rich in iron National policy makers, food and agriculture sectors Implement actions to ensure that pregnant and lactating adolescent mothers are National policy makers, development partners, food and agriculture sectors adequately nourished Introduce measures to prevent adolescent pregnancy and to encourage pregnancy National policy makers, health service providers spacing Reduce the risk of low birth weight, maternal anaemia, and iron deficiency Provide daily iron and folic acid and other micronutrient supplementation to National policy makers, health service providers pregnant women as part of antenatal care Provide intermittent iron and folic acid supplementation to menstruating women National policy makers, health service providers where prevalence of anaemia is 20% or higher Provide periodic treatment with anthelminthic (deworming) medicines for all National policy makers, health service providers, development partners women of childbearing age living in endemic areas Promote healthy weight gain and adequate nutrition during pregnancy Provide dietary counselling to women during pregnancy National policy makers, health service providers Prevent and treat malaria as part of anaemia prevention and control Ensure universal access to and use of insecticide treated nets National policy makers, health service providers, development partners Provide preventive malaria treatment for pregnant women in areas with moderate to National policy makers, health service providers, development partners high malaria transmission Ensure access to reproductive healthcare Ensure that women have comprehensive information about safe pregnancy and National policy makers, health service providers, development partners delivery Ensure that women have access to integral healthcare services that ensure National policy makers, health service providers, development partners adequate support for safe pregnancy and delivery Promote protection of working mothers to support or sustain breast feeding Implement policies and practices to promote protection of working mothers (eg, National or regional policy makers, employers longer maternity leave, breaks to feed or express breast milk) Improve pregnancy outcomes for undernourished pregnant women To prevent pre-eclampsia, provide calcium supplementation for pregnant women in National policy makers, health service providers, development partners areas where dietary calcium intake is low and for higher risk women21* All recommended actions are based on those proposed in the Framework for Action issued by the Second International Conference on Nutrition in November 2014 except (*),which is based on a WHO recommendation.

3 World Health Organization. WHA global nutrition 13 World Health Organization. Global nutrition targets inaction are high. The time is right to tackle targets 2025: stunting policy brief. 2014. www.who. 2025: childhood overweight policy brief (WHO/NMH/ malnutrition in all forms at all ages and to int/nutrition/topics/globaltargets_stunting_ NHD/14.6). 2014. ­www.who.int/nutrition/topics/ policybrief.pdf. globaltargets_overweight_policybrief.pdf. break its intergenerational cycle. 4 World Health Organization. WHA global nutrition 14 United Nations. The millennium development goals The authors thank Karen McColl, Lina Mahy, Rebecca targets 2025: wasting policy brief. 2014. www.who. report 2014. 2014. www.un.org/ Olson, and Shelly Sundberg for their contributions int/nutrition/topics/globaltargets_wasting_ millenniumgoals/2014%20MDG%20report/MDG%20 to this paper. policybrief.pdf. 2014%20English%20web.pdf. 5 Black RE, Victora CG, Walker SP, et al; Maternal and 15 World Health Organization. Essential nutrition actions: Competing interests: We have read and understood Child Nutrition Study Group. Maternal and child improving maternal, newborn, infant and young child BMJ’s policy on declaration of interests and have no undernutrition and overweight in low income and health and nutrition. 2013. http://apps.who.int/iris/ relevant interests to declare. middle income countries. Lancet 2013;382:427-51. bitstream/10665/84409/1/9789241505550_eng.pdf. The authors alone are responsible for the views 6 Lim SS, Vos T, Flaxman AD, et al. A comparative risk 16 United Nations. The Addis Ababa action agenda of expressed in this article, which does not necessarily assessment of burden of disease and injury the Third International Conference on Financing for represent the views, decisions, or policies of WHO or the attributable to 67 risk factors and risk factor clusters in Development. July 2015. www.un.org/esa/ffd/ffd3/ 21 regions, 1990-2010: a systematic analysis for the wp-content/uploads/sites/2/2015/07/Addis-Ababa- institutions with which the authors are affiliated. Global Burden of Disease Study 2010. Lancet Action-Agenda-Draft-Outcome-Document-7-July-2015. Provenance and peer review: Not commissioned; 2012;380;2224-60. pdf. externally peer reviewed. 7 International Bank for Reconstruction and 17 International Food Policy Research Institute. Global Development, World Bank. Repositioning nutrition as nutrition report 2014: actions and accountability to Francesco Branca, director1 central to development: a strategy for large scale accelerate the world’s progress on nutrition. 2014. Ellen Piwoz, senior program officer2 action. 2006. https://openknowledge.worldbank.org/ http://cdm15738.contentdm.oclc.org/utils/getfile/ handle/10986/7409. collection/p15738coll2/id/128484/filename/128695. Werner Schultink, chief of nutrition3 8 World Health Organization. Comprehensive pdf. Lucy Martinez Sullivan,  executive director4 implementation plan on maternal, infant and young 18 World Health Organization. Healthy diet. Fact sheet no child nutrition. 2014. http://apps.who.int/iris/ 394. May 2015. www.who.int/mediacentre/factsheets/ 1Department of Nutrition for Health and Development, bitstream/10665/113048/1/WHO_NMH_NHD_14.1_ fs394/en/. World Health Organization, Avenue Appia 20, 1211 eng.pdf?ua=1. 19 World Health Organization. Global recommendations Geneva 27, Switzerland 9 Hoddinott J, Alderman H, Behrman JR, Haddad L, on physical activity for health. 2010. www.who.int/ 2Bill and Melinda Gates Foundation, USA Horton S. The economic rationale for investing in dietphysicalactivity/publications/9789241599979/ stunting reduction. GCC Working Paper Series en/. 3Unicef, New York, USA 2013;13-08. 20 World Health Organization. Nutrition counselling for 41000 Days, Washington, DC, USA 10 Hoddinott J, Horton S. Stunting as a sustainable adolescents and adults with HIV/AIDS. WHO e-Library Correspondence to: F Branca [email protected] development goal. SCN News 2015;41:59. www.unscn. of Evidence for Nutrition Actions (eLENA). July 2015. org/files/Publications/SCN_News/SCNNEWS41_web_ www.who.int/elena/titles/nutrition_hiv/en/. 1 Second International Conference on Nutrition. low_res.pdf. 21 World Health Organization. Guideline: calcium Conference outcome document: framework for 11 United Nations Secretary General. Global strategy for supplementation in pregnant women. 2013. www.who. action. Oct 2014. www.fao.org/3/a-mm215e.pdf. women’s and children’s health. Sept 2010. www.who. int/nutrition/publications/micronutrients/guidelines/ 2 Second International Conference on Nutrition. int/pmnch/topics/maternal/20100914_gswch_en.pdf. calcium_supplementation/en/. Information note on the framework for action. 4 Nov 12 Second International Conference on Nutrition. 2014. www.fao.org/fileadmin/user_upload/faoweb/ Conference outcome document: Rome declaration on ICN2/documents/InfoNote-e.pdf. nutrition. Oct 2014. www.fao.org/3/a-ml542e.pdf. Cite this as: BMJ 2015;351:h4173

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Improving the resilience and workforce of health systems for women’s, children’s, and adolescents’ health To achieve the sustainable development goals related to maternal, child, and adolescent health, countries need to integrate targeted interventions within their national health strategies and leverage them into financing, workforce, and monitoring capacity across the system, say James Campbell and colleagues.

he United Nations’ first Every force, supply chain, information systems, sustainability being often undermined by Woman Every Child strategy, Global and service delivery.3 In this paper we high- lack of integration into national health sys- Strategy for Women’s and Chil- light two core aspects that require urgent tems. Even where efforts have been made to dren’s Health, provided an impetus attention—building the resilience of health embed services at the community level, such “to improve the health of hundreds systems and ensuring sufficient human as in the roll-out of integrated community ofT millions of women and children around resources. case management of childhood illness pro- the world and, in so doing, to improve the grammes, a lack of full integration and stew- lives of all people.”1 The updated Global Methods ardship by national health systems has Strategy for Women’s, Children’s and Ado- Our analysis is informed by lessons from hindered service use and sustainability.8 lescents’ Health calls for an even more ambi- countries that have made the most rapid Disease specific approaches often fail to tious agenda of expanding equitable progress on millennium development goals tackle the delivery of services for other dis- coverage to a broader range of reproductive, 4 (to reduce child mortality rates), 5 (to eases or to sustainably strengthen common maternal, newborn, child, and adolescent improve maternal health), and 6 (to combat delivery platforms.9 Despite both method- health services, as integral to the 2030 tar- HIV/AIDS, malaria, and other diseases) since ological and data limitations in the evi- gets of the sustainable development goals.2 2000. In addition, we draw on the experi- dence,10 there are clear indications that These goals cannot be realised by efforts ences of several countries in the recent out- working towards integrated service delivery that tackle only specific parts of the global break of Ebola virus disease, new evidence can improve healthcare use and outcomes.11 strategy. Instead, an integrated approach is on the workforce requirements for achieving The desire for focus on specific conditions is required, to include the complementary universal health coverage,4 5 and the forth- understandable, but efforts need to be functions of stewardship, financing, work- coming WHO Global Strategy on Human aligned with and steered by national health Resources for Health: Workforce 20306 and systems and must be accompanied by delib- WHO Global Strategy on People Centred and erate attempts to create synergies with other Key messages Integrated Health Care Services,7 which priorities of the health system. Achieving the ambitious agenda of the describe innovative ways to deliver services A further challenge is the insufficient resil- global Every Woman Every Child strategy and organise workforces. These two strate- ience of many health systems to withstand requires improved efforts at strengthening gies are the product of iterative and broad shocks and adapt to changing needs.12 The health systems, building their resilience, consultation processes, multiple literature recent outbreak of Ebola highlighted how and tackling critical health workforce reviews, and advice from expert groups. We progress in women’s, children’s, and adoles- challenges cross checked key findings from these analy- cents’ health can be fragile in weak health Targeted programmes relating to ses with the contents of the revised Every systems (box 1). reproductive, maternal, newborn, child, Woman Every Child strategy. In Liberia skilled birth attendance fell from and adolescent health should be led by 52% to 38% and vaccination rates for measles countries and be integrated into national Fragmentation of care and weak service and combined diphtheria, tetanus, and per- health systems delivery systems tussis fell to 45% and 53%, respectively, during Governments should integrate Progress in achieving the millennium devel- the outbreak. At the height of the outbreak, international support for targeted opment goals has been substantive but 64% of all Liberian health facilities were not interventions within their national health uneven, with its equity, effectiveness, and operational (WHO, unpublished data). Sierra strategies and leverage these programmes into financing, workforce, and monitoring capacity across the system Box 1: Weak health systems lack resilience The global strategy should consider The resilience of a health system is its capacity to respond, adapt, and strengthen when exposed to the health system and workforce a shock, such as a disease outbreak, natural disaster, or conflict. In weak health systems (such as implications of its targets. It should those lacking core capacity in governance, financing, health workforce, or information systems), the promote commitments, investment, and ability of both the clinical and public health workforce to respond to planned and unplanned needs is limited, and gains can easily be reversed. In the most severe phases of the continuing Ebola outbreak accountability from both national and in west Africa the needs of women for antenatal services, safe delivery, and postnatal care were not international sources that encourage met. The capacity of the health system to continue delivery of essential health services and respond to sustainable investment in health systems the health crisis was limited, highlighting the need for substantial investment in, and improvement of, and the health workforce health systems.13

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Box 2: Future trends in the global health labour market priate incentive systems, and models of A projected shortfall of skilled health professionals (doctors, nurses, and midwives) of 10.1 million by healthcare delivery that harness a more 2030 has been identified, a challenge compounded by uneven geographic distribution.6 Sub-Saharan diverse and sustainable skills mix. Africa is the most affected region in both absolute and relative terms, with a projected deficit of 3.7 Prevention and control of infection are million healthcare workers. Sustainable development goal 3.c appropriately calls for a substantial also important. Disease surveillance and increase in health financing and in the recruitment, development, training, and retention of the health information systems that use new technolo- workforce in developing countries.16 At the same time, global demand for health workers will rise to gies, such as mobile phones and rapid data 45 million additional professionals by 2030. A disparity exists, however, between population needs collection forms, are the key to collecting and market based demands, as those countries where basic health needs are the greatest have the geographically targeted data, which can be fewest economic resources to create employment positions in the public health sector. The proposed sustainable development goals, which are implicit in the Every Woman Every Child strategy, will not used for decision making and improvement be achieved without unprecedented international governance and solidarity, together with innovative of care. national approaches to maximise the efficiency of available resources. Broader efforts at strengthening health system governance, including planning, Leone reported that 21% fewer children Leadership and integration at national level monitoring, and accountability of policy received basic immunisation. In Guinea diph- All health programmes—whether funded by makers, are also needed for effective health theria, tetanus, and pertussis coverage governments, development partners, civil service delivery. Strengthening and building dropped by 30% between 2013 and August society, or the private sector—must contrib- up these capacities are pre-conditions for 2014 (Ministere de la Santé, unpublished). ute to national priorities set by governments. effective health service delivery, especially in The health workforce, from the commu- To achieve this requires improved gover- fragile states and contexts with weak gover- nity level to specialist care, is critical in nance of health systems, better coordination nance, where they may also contribute to building resilient health systems. Progress in between national and sub-national systems, broader state building efforts.24 strengthening human resources for health and mobilisation of sufficient financing with currently falls short of population needs better cash flow.19 Some of the countries that Improving the workforce (box 2).14 15 have made the greatest gains in maternal, Optimising the competence and capacity of child, and adolescent health are those where the health workforce can bring key services, Disrupting the status quo national governments have skilfully bro- such as contraception, closer to communi- The Every Woman Every Child strategy kered international support for targeted ties and improve coverage of key interven- should create a new agenda characterised by interventions and integrated these initiatives tions to reduce maternal, neonatal, and fetal several key elements: into existing financing, workforce, and mon- morbidity and mortality from obstetric com- itoring capacities within their national plications. The “obstetric transition” of sus- • Approaches based on public health and health systems.20-22 Other countries have tainable development goal 3.1 requires a social determinants, which reduce improved their health outcomes by compre- health workforce that can provide obstetric demand on costly clinical services, are hensively strengthening their health work- and newborn services and access to family critical components of a resilient health force and using integrated platforms for planning.25 Essential health and supporting system,17 and improvements in the cover- delivery of care in the community.23 Promot- services will need to be scaled up, particu- age of health services are linked to prog- ing the exchange of knowledge and resources larly in the prevention of maternal and new- ress in sectors such as nutrition, water and from these success stories, and using them born deaths and stillbirths.26 Similarly, sanitation, education, and transportation. as benchmarks, can accelerate progress in better distribution of skilled health profes- • People centred, integrated health services other countries. sionals, with a particular focus on the mid- are required throughout the life cycle, wifery workforce, will be needed.27 Despite from early infant and child development, Building resilience international recommendations, midwives through adolescent, adult, and ageing The development of mechanisms to ensure in many countries are not empowered to pro- populations. continued delivery of essential health ser- vide the basic functions of emergency obstet- • Community engagement is needed to vices during a health shock must include the ric care, including the use of vacuum establish trust between patients and the capacity to cater to the special needs of extraction for difficult childbirth. New com- health system and to empower patients to women and children. The importance of put- petencies will be needed to meet the addi- become active participants in, rather than ting people at the centre of delivery of health tional service needs for youth and adolescent passive recipients of, care.18 Health sys- services was apparent in the ongoing Ebola health, reproductive cancers, and to tackle tems need to be deliberately designed to outbreak—during the initial response, the the risk factors of childhood obesity. narrow equity gaps. early recovery phase, and long term plan- • The health and social care workforce are ning for resilience. This entails renewed people working in dynamic labour mar- focus on sub-national delivery systems (par- Policy planning kets with responsibilities and rights—their ticularly at community and district levels), Workforce opportunities for decent work and occupa- on quality improvements, and on strength- Infection health, tional health and safety are consistent prevention ening national disease surveillance and education, and control with sustainable development goal 8, for response (figure). and incentives decent work for all. Strengthening the workforce is a core ele- Resilience • Finally, health systems are diverse, and ment of this agenda, and it must encompass Key entry points the agenda needs to be adapted to differ- both short term measures—such as health ent socioeconomic contexts—for example, and safety programmes, continuing training Information Safe and essential enhanced capacity building and support- and supportive supervision, and community surveillance services ive investments from external sources will engagement—and recovery measures, such be needed in fragile states characterised as increasing the fiscal space, adopting edu- by weak governance and leadership. cation strategies, developing locally appro- Entry points to health system resilience

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Evidence has shown the potential for com- evaluating human resources for health inter- decisions that recognise the centrality of munity based and mid-level practitioners to ventions.6 building health system resilience and provide expanded coverage of other essen- Much can be achieved if a global and com- strengthening the health workforce. Sec- tial interventions for maternal, child, and prehensive approach is implemented to ondly, it should include explicit targets and adolescent health.28 29 Such practitioners tackle market failures and create the condi- related accountability mechanisms that refer must be adequately supported by health sys- tions for future health employment (particu- to the health systems and workforce needs. tems that enable their optimisation and sus- larly for women and young people) and Finally, it should facilitate the adoption of tainability (as in Bangladesh, Brazil, economic growth. A measurement and funding approaches by related initiatives, Ethiopia, Mozambique, Pakistan, Thailand, accountability framework for the sustainable such as the Global Financing Facility, that and others).30 31 development goals can provide the founda- encourage long term investment in capital Optimising the health workforce will also tions for new investments in national and and recurrent costs for health systems. contribute to sustainable development goals sub-national health workforce information We thank Mwansa Nkowane (WHO), Laurence Codjia 2 (end hunger, achieve food security and systems,6 and enable the implementation of (WHO), Amani Siyam (WHO), Nadia Yakhelef (WHO), Metin Gulmezoglu (WHO), Edson Araujo (World Bank), improved nutrition, and promote sustainable a mechanism to standardise health work- Caroline Homer (University of Technology, Sydney), agriculture), 3 (ensure healthy lives and pro- force information across countries. Such a Emmanuel Makasa (Counsellor Health, Zambia Mission, mote wellbeing for all at all ages), 4 (ensure mechanism would be based on agreed health Geneva), Francisco Pozo-Martin (ICS Integrare), Luisa Pettigrew (WONCA), Lynn P Freedman (Columbia inclusive and equitable quality education workforce indicators and could produce the University Medical Center), Paidamoyo Sharon Muyambo and promote lifelong opportunities for all), 5 information needed to facilitate health work- (Zimbabwe Mission, Geneva), Lola Dare (CHESTRAD), Jim (achieve gender equality and empower all force planning and management. Buchan (University of Technology, Sydney), Marie-Noel Brune Drisse (WHO), Margaret Murphy (University women and girls), 6 (ensure availability and College Cork, Ireland), Carole Kenner (School of Nursing, sustainable management of water and sani- Conclusions Health and Exercise Science The College of New Jersey, tation for all), and 8 (promote sustained, The updated Every Woman Every Child strat- USA), Jan-Willem Scheijgrond (Philips), Ryan Mulligan (World Vision), and Cindil Redick (Columbia University, inclusive, and sustainable economic growth, egy must place health systems at its heart, as USA). The insightful and constructive comments by the full and productive employment, and decent their performance will decide success or fail- peer reviewers are also gratefully acknowledged. work for all), as well as the updated Every ure for reproductive, maternal, newborn, Contributors and sources: We received input for this Woman Every Child targets.32 ­33 child, and adolescent health in the next 15 article from: an expert group (listed in the Acknowledgments section); a consultation in Abidjan, Cote Evidence from high income countries years. Achieving the health goals of the new d’Ivoire (13 February 2015); an event coordinated by WHO shows that despite a rise in unemployment 2030 agenda will require augmented efforts (Does the world have enough midwives? 23 February in the manufacturing and construction sec- to build integrated healthcare delivery sys- 2015); feedback from the Delhi Stakeholders Meeting (26-27 February 2015), and review from the Every Woman tors health sector employment has remained tems, aligning market forces and population Every Child Steering Group. JC developed first draft of the stable or grown during the recession.34 expectations for essential and universal article. GC led development of revisions of all subsequent Emerging economies are undergoing an eco- care. This will require a radical transforma- drafts. KR contributed substantive technical contents on most sections of the document. EK and SS contributed nomic transition that will increase the health tion of implementation efforts at the country contents particularly on health service delivery reforms resource budget and a demographic transi- level. All programmes must be integrated and health systems resilience. PZ, LdB, ZM, DB, OF, and AN tion that will see hundreds of millions of into national health systems so they can be contributed significant contents on specific sections of the manuscript. Meet ICMJE criteria for authorship: JC, GC, KR, potential new entrants in the active work- reconfigured to meet changing national EK, SS, PZ, LdB, ZM, DB, OF, AN. JC is the guarantor. force. These prospects create an unprece- needs. National and global governance must Conflicts of interest: We have read and understood BMJ dented opportunity to design and implement be overhauled to deliver a substantive policy on declaration of interests and declare that we health workforce strategies to tackle the scale-up of domestic public sector and inter- have no competing interests. Provenance and peer review: Not commissioned; gaps in equity and coverage faced by health national financing to meet systems and externally peer reviewed. systems, while also contributing to economic workforce needs. Health and social care The authors alone are responsible for the views growth potential.35 The volume and growth should be recognised not just as rights but as expressed in this article, which does not necessarily of global health expenditures, which opportunities for employment creation (par- represent the views, decisions, or policies of WHO or the institutions with which the authors are affiliated. exceeded $6 trillion (£3.8 trillion; €5.5 tril- ticularly for young people and women) and James Campbell,executive director, Global Health lion) a year by 2010, confirm that health is a economic growth. In addition, expanding Workforce Alliance director, health workforce1 sector with potential for substantial eco- the workforce is a good investment for imple- Giorgio Cometto, technical officer, Global Health nomic growth.36 mentation of the sustainable development Workforce Alliance1 To design and implement an enhanced goals. The existing systems and workforce Kumanan Rasanathan,  senior health specialist2 workforce agenda, national institutions need to be optimised, which can be made Edward Kelley, director, Service Delivery and Safety1 need to develop the capacities for collecting, possible by stronger national institutions Shamsuzzoha Syed, technical officer, Service Delivery and Safety1 collating, and analysing (public and private) that are able to devise and implement more Pascal Zurn, technical officer, Health Systems Evidence workforce data and labour economics; lead- effective strategies. Capacity must be built at and Policy3 ing short and long term health workforce the local level to monitor health service Luc de Bernis, senior maternal health adviser4 planning and development; advocating for delivery and inform policy change. Zoe Matthews, consultant4 better employment and working conditions Securing the necessary political will, David Benton,  chief executive officer5 for health workers; designing, developing, ensuring effective governance in countries, Odile Frank, health and social services officer6 and delivering enhanced pre-service and aligning the required efforts of different sec- Andrea Nove, senior research associate7 in-service education and training for health tors and constituencies in society, and 1World Health Organization, Avenue Appia 20, 1207, workers; supporting health professional accountability are critical to achieving this Geneva, Switzerland 2 associations; facilitating collaboration with, ambitious vision. The updated Every Woman Unicef, United Nations Plaza, New York, USA 3Country Office in India, WHO, Indraprastha Estate, New and regulation of, private sector educational Every Child strategy could contribute to this Delhi, India institutions and health providers; oversee- agenda in several ways. Firstly, it could pro- 4United Nations Population Fund, New York, USA ing the design of fair and effective perfor- mote the development of international com- 5International Council of Nurses, 3 Place Jean-Marteau, mance management; and monitoring and mitments, national plans, and investment 1201, Geneva, Switzerland

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6Public Services International, BP 9, 01211 Ferney- 11 Dudley L, Garner P. Strategies for integrating primary 25 Souza JP, Tuncalp Ö, Vogel JP, et al. Obstetric transition: Voltaire, CEDEX, FRANCE health services in low- and middle-income countries at the pathway towards ending preventable maternal the point of delivery. Cochrane Database Syst Rev deaths. BJOG 2014;121 Suppl 1:1-4. 7ICS Integrare, Barcelona, Spain 2011;7:CD003318. 26 United Nations. Saving lives, protecting futures. Correspondence to: J Campbell [email protected] 12 Hollnagel E. Resilience: the challenge of the unstable. In: Progress report on the global strategy for women’s and Hollnagel E, Woods DD, Leveson N, eds. Resilience children’s health. 2015. www.who.int/life-course/ 1 United Nations. Secretary-general’s remarks at the engineering: concepts and precepts. Ashgate, 2006: 9-18. news/ewec-progress-report-2015.pdf. launch of the global strategy for women’s and children’s 13 Kieny MP, Evans DB, Schmets G, Kadandale S. 27 UNFPA. The state of the world’s midwifery 2014. A health—“Every Woman, Every Child.” 22 Sep 2010. Health-system resilience: reflections on the Ebola universal pathway. A woman’s right to health. 2014. www.un.org/sg/STATEMENTS/index.asp?nid=4796. crisis in western Africa. Bull World Health Organ www.unfpa.org/sowmy. 2 The Partnership for Maternal, Newborn, and Child 2014;92:850. 28 Lewin S, Munabi-Babigumira S, Glenton C, et al. Lay Health. Global strategy for women’s, children’s, and 14 World Health Organization. World Health Report 2006. health workers in primary and community health care adolescents’ health. www.who.int/pmnch/activities/ Working together for health. www.who.int/whr/2006/ for maternal and child health and the management of advocacy/globalstrategy/en/. en/index.html. infectious diseases. Cochrane Database Syst Rev 3 World Health Organization. Everybody’s business. 15 World Health Organization. Every woman, every child: a 2010;3:CD004015. Strengthening health systems to improve health post-2015 vision. 2014. http://apps.who.int/iris/ 29 Lassi Z, Cometto G, Huicho L, Bhutta ZA. Quality of care outcomes. WHO’s framework for action. 2007. www. bitstream/10665/132673/1/9789241507523_eng.pdf. provided by mid-level health workers: systematic who.int/healthsystems/strategy/everybodys_ 16 United Nations Division for Sustainable Development. review and meta-analysis. Bull World Health Organ business.pdf. Open working group proposal for sustainable 2013;91:824-33. 4 Global Health Workforce Alliance, World Health development goals. http://sustainabledevelopment. 30 Global Health Workforce Alliance. Global experience of Organization. A universal truth: no health without a un.org/focussdgs.html. community health workers for delivery of health related workforce. Third global forum on human resources for 17 Marmot M, Friel S, Bell R, Houweling TA, Taylor S; millennium development goals: a systematic review, health report. Nov 2013. www.who.int/workforcealliance/ Commission on Social Determinants of Health. Closing the country case studies, and recommendations for knowledge/resources/hrhreport2013/en/. gap in a generation: health equity through action on the integration into national health systems. 2010. www. 5 Special theme issue: human resources for universal social determinants of health. Lancet 2008;372:1661-9. who.int/workforcealliance/knowledge/resources/ health coverage. Bull World Health Organ 2013;91:​ 18 Global Health Workforce Alliance. Building capability chwreport/en/. 797-896. beyond the health sector to deliver universal health 31 Tulenko K, Møgedal S, Afzal MM, et al. Community 6 Global Health Workforce Alliance, WHO. Synthesis coverage. Technical Working Group 8 for the global health workers for universal health-care coverage: from paper of the thematic working groups. Towards a strategy on human resources for health. 2015. www. fragmentation to synergy. Bull World Health Organ global strategy on human resources for health. Apr who.int/workforcealliance/media/news/2014/ 2013;91:847-52. 2015. www.who.int/hrh/documents/synthesis_paper_ TWG8_capacitybeyondhealthsector.pdf?ua=1. 32 De Francisco Shapovalova N, Meguid T, Campbell J. them2015/en/. 19 Lie GSS, Soucat ALB, Basu S. Financing Women’s, Health-care workers as agents of sustainable 7 World Health Organization. WHO global strategy on children’s and adolescents’ health. BMJ 2015;351:​ development. Lancet Glob Health 2015;3:e249-50. people-centred and integrated health services. 2015. h4267. 33 United Nations. The road to dignity by 2030: ending www.who.int/servicedeliverysafety/areas/ 20 Binagwaho A, Farmer PE, Nsanzimana S, et al. Rwanda poverty, transforming all lives and protecting the people-centred-care/en/. 20 years on: investing in life. Lancet 2014;384:371-5. planet. Dec 2014. www.un.org/disabilities/documents/ 8 Rasanathan K, Bakshi S, Rodriguez DC, et al. Where to 21 Amouzou A, Habi O, Bensaïd K. Reduction in child reports/SG_Synthesis_Report_Road_to_Dignity_ from here? Policy and financing of integrated mortality in Niger: a countdown to 2015 country case by_2030.pdf. community case management (iCCM) of childhood study. Lancet 2012;380:1169-78. 34 Eurofound. Employment polarisation and job quality in illness in sub-Saharan Africa. J Glob Health 2014;4:​ 22 Nefdt R, Marsh DR, Hazel E. Conclusions: delivering the crisis. European Jobs Monitor 2013. www.eurofound. 020304. integrated community case management (ICCM) to europa.eu/pubdocs/2013/04/en/1/EF1304EN.pdf. 9 World Health Organization Maximizing Positive treat childhood illness at scale in Ethiopia. Ethiop Med J 35 Global Health Workforce Alliance. Economic, Synergies Collaborative Group, Samb B, Evans T, et al. 2014;52 Suppl 3:1630-7. demographic, and epidemiological transitions and the An assessment of interactions between global health 23 Campbell J, Buchan J, Cometto G, et al. Human future of health labor markets. Sep 2014. www.who. initiatives and country health systems. Lancet resources for health and universal health coverage: int/workforcealliance/media/news/2014/ 2009;373:2137-69. fostering equity and effective coverage. Bull World WG1_SynthesisSept282014.pdf?ua=1. 10 Vasan A, Ellner A, Lawn SD, et al. Integrated care as a Health Organ 2013;91:853-63. 36 World Health Organization. Spending on health: a means to improve primary care delivery for adults and 24 Witter S, Falisse JB, Bertone MP, et al. State-building global overview. Fact sheet 319. Apr 2012. www.who. adolescents in the developing world: a critical analysis and human resources for health in fragile and int/mediacentre/factsheets/fs319/en/. of Integrated Management of Adolescent and Adult conflict-affected states: exploring the linkages. Hum Illness (IMAI). BMC Med 2014;12:6. Resour Health 2015;13:33. Cite this as: BMJ 2015;351:h4148

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Ensuring multisectoral action on the determinants of reproductive, maternal, newborn, child, and adolescent health in the post-2015 era Kumanan Rasanathan and colleagues explain how integrating action on determinants of women’s, children’s, and adolescents’ health beyond the health sector into core health strategies is crucial to achieving sustainable development goal targets to end preventable deaths and ensure healthy lives

espite impressive improvements Woman Every Child 2.0; EWEC 2.0) also make resources, and infrastructure improvements since the launch of the millen- it timely to consider how multisectoral action (roads, electricity, housing, information and nium development goals (MDGs), can be facilitated in countries, including in communications technology) can also many countries will not reach the updating and developing new national strat- reduce maternal mortality.10 Interactions targets on maternal and child mor- egies for reproductive, maternal, newborn, between different determinants, such as the Dtality, partly because of the lack of attention to child and adolescent health (RMNCAH). Here impact of women’s and girls’ education on determinants of health (box 1) beyond the we review evidence on the contribution of fertility rates and their joint impact on health health sector. For example, the 2010-15 Global action on determinants, discuss major obsta- outcomes, are also important.11 Strategy for Women’s and Children’s Health, cles, and propose key steps for global and Structural societal factors, such as poverty, launched by the United Nations secretary national strategies to provide guidance. gender inequality, and other forms of discrim- general to accelerate progress on MDGs 4-6,1 ination (such as racism) and inequality failed to consider determinants of health or Methods directly and indirectly affect RMNCAH and interventions beyond the health sector. The The conclusions and recommendations in this generate health inequities. Interventions to maturation of the goals this year provides an article are drawn from a review of the litera- mitigate these adverse factors (such as reduc- opportunity to reflect on how coordinated ture, estimates of the effects of interventions, ing poverty, ending child marriage, or tack- multisectoral action could achieve more country lessons, and the authors’ experiences. ling violence against women and children) ambitious targets for women and children’s The range of products from the Commission help improve women’s, children’s, and ado- health, such as ending preventable maternal, on Social Determinants of Health2 and the lescents’ health, but there is a lack of compre- newborn, and child deaths in all countries. Success Factors5 project provided key inputs, hensive evidence of the effects of specific The finalisation of the 2016-30 sustainable along with multiple rounds of consultation interventions on mortality. The correlation development goals (SDGs; which urge a more undertaken as part of the process of updating between economic growth and improvements integrated and transformative view of devel- the global strategy, which included online and in maternal and child mortality is complex, opment) and the upcoming launch of the face to face consultations. with wide variations in performance between 2016-30 Global Strategy for Women’s, Chil- countries of similar wealth levels,12 mediated dren’s and Adolescents’ Health (Every The determinants of health paradox: by differences in health systems and determi- increasing recognition but limited action nants. This underscores the importance of Progress on RMNCAH can be accelerated by policy choices and attention to inequities in Key messages interventions beyond the health sector. The health and wealth, and of prioritising new Social, economic, political, environmental, contribution of non-health sectors, includ- resources for marginalised communities, and cultural determinants of health have ing the contributions of different sectors and which often lack political influence. Globally crucial effects on reproductive, maternal, interventions, is best understood for mortal- there has been a call for attention to transna- newborn, child, and adolescent health ity in children under 5.6 About half the tional and commercial determinants of health The goal of ending preventable decrease in child mortality in low and mid- given their increasing impact on health and maternal, newborn, and child deaths dle income countries since 1990 is due to widening disparities.13-15 requires multisectoral action to improve non-health sector investments.5 Multisectoral efforts to improve determi- determinants of health, including within Estimates for the contribution of educa- nants of health are therefore extremely the health sector itself tional improvement vary—as high as 51.2% important for RMNCAH—to reduce inequities, Key steps to improving determinants for 1970-2009.7 Malnutrition remains the create healthier environments, and increase of health include appropriately framing underlying cause of 45% of child deaths.8 coverage of health interventions. The related determinants and multisectoral action in Environmental factors are important con- millennium and sustainable development health strategies; identifying key targets tributors to diarrhoea, malaria, and respira- goals will not be achieved without them. For and indicators; prioritising key policies and tory infections (among the greatest causes of example, no country has reduced newborn interventions; and mobilising resources, death in children under 5), as well as injury and child mortality to the SDG target levels improving governance, and generating and malnutrition. About a third of all disease through healthcare alone, without transfor- evidence of multisectoral efforts in children can be attributed to modifiable mations in social and economic development. We propose the convening of a new United environmental factors such as water quality Evidence on which policies and interventions Nations commission on implementation and access, air pollution, unsafe sanitation, are necessary is also accumulating.16 and accountability of multisectoral action exposure to chemicals, and climate change.9 Despite the eight MDGs being presented as for women’s, children’s, and adolescents’ Better female education, reduced fertility a joint agenda, including key determinants, health to assist these efforts rates, urbanisation, women’s access to in practice the different goals were not

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• Supporting actions within single sectors Box 1: Determinants of health that form their core business (such as The determinants of health are the conditions in which people are born, grow, live, work, and age, and the distribution of power, money, and resources that affect these conditions.2 They encompass social, ensuring children attend school and learn economic, political, environmental, and cultural dimensions. Here, we use “determinants” to cover all well for the education sector, access to of these factors (“social determinants of health”2 or “underlying determinants”3 are sometimes used safe water for the water and sanitation in a similar way). sector, or access to clean power for the Determinants crucially influence the health of women, children, and adolescents, who often energy sector) experience discrimination and unequal access to resources and realisation of their rights, resulting in • Ensuring the health sector recognises its exposure to adverse socioeconomic, political, and environmental conditions. These factors directly own role in generating health disparities cause inequities of health in this population within and between countries. Determinants affect (such as discrimination and abuse, provi- access and coverage of essential health interventions and directly affect health, including through the shaping of social norms and behaviours. sion of differential quality of care to differ- Gender (in)equality is a key determinant of health that transcends sectors and illustrates this ent groups, and inadequate water and concept well.4 Manifestations of gender inequality (such as differential access to education energy supplies to health facilities) and and health services, forced and early child marriage, unequal labour market participation and maximises its key role in primary preven- remuneration, and violence against women and children) are major contributors to maternal and tion child mortality. Measures to mitigate these factors can improve health outcomes and reduce • Identifying, promoting, and co-financing disparities. actions that require collaboration between Determinants are not static but interact with each other and change with the evolving context. two or more sectors (intersectoral work) Action within various sectors (such as health, education, water and sanitation, environment to produce joint or “co-benefits” and to related sectors, and nutrition) and joint action across and between sectors (cross sectoral and intersectoral action) is needed to improve determinants. maximise health benefits (such as the use of cleaner stoves to reduce indoor air ­pollution, or sexuality education in managed­ together.17 Improvements in health tion, and monitoring will need to be schools). service coverage have been crucial to prog- addressed to change the status quo. Although work on determinants often ress in MDGs 4-6, but the contribution of One obstacle to engaging other sectors has focuses on intersectoral efforts, the greatest multisectoral interventions to the health spe- been the lack of clear mechanisms for public benefits often lie in the first two activities cific goals has been insufficiently tracked and social accountability for RMNCAH. above—addressing structural forces and and documented. This failure to recognise Despite progress in accountability within the social and gender norms (for example, the importance of key policies across a range health sector at global and national levels reducing poverty or increasing gender equal- of sectors undermines efforts to reach (including through the Commission on Infor- ity) and single sectors doing their own core RMNCAH outcome targets, as well as efforts mation and Accountability for Women’s and business well. For example, for the educa- to increase coverage of healthcare interven- Children’s Health), little attention has been tion sector, keeping adolescent girls in tions. Identifying why some groups have paid to increasing the accountability of other school and providing a good education that lower health service coverage, even in coun- sectors. This gap reflects how responsibility enables their economic empowerment has tries with overall strong performance, for maternal, child, and adolescent health is greater health impact than collaborative requires a focus on, and measurement of, still perceived as the interest of the health activities to increase health literacy or determinants such as discrimination, pov- sector only. undertake school based health clinics.7 11 19 erty, and gender inequality. All providers of When considering multisectoral action, the healthcare (including faith based organisa- What is now needed for action on health sector has too often focused on mar- tions) must be considered and interventions determinants of RMNCAH ginal collaborations at the expense of recog- in other sectors such as roads, utilities, and Ensuring multisectoral action on determi- nising the impact of the core work of other finance proritised. The effects of deficiencies nants of RMNCAH will require prioritisation sectors. in other sectors on health systems have been and resources to overcome the obstacles dis- Determinants also influence global and neglected—a recent review of healthcare cussed above. Global and national strate- national leadership, accountability, and the facilities found that 38% lacked water, 19% gies, including EWEC 2.0, can contribute by actions of the health and other sectors. had no sanitation, and 35% lacked water and integrating a focus on determinants as “core Structural inequities in power at global, soap for handwashing.18 business.” We propose four key steps for national, district, and community levels Investment in institutions to advocate inclusion in such strategies. obstruct the policy and implementation for, pioneer new approaches, or regulate choices needed for equitable delivery of multisectoral work has also been inade- 1. Framing determinants and multisectoral essential services and for harnessing the quate. Working across sectors for health has action resources needed for multisectoral imple- proved challenging, especially in settings The health sector often lacks conceptual mentation. The MDGs were not explicitly with a high RMNCAH burden. The challenge and practical understanding of determi- aimed at reducing these imbalances in is not just how to identify the key interven- nants of RMNCAH and multisectoral action. power, and although the SDGs focus on tions in non-health sectors but how to New global and national strategies need inequality more explicitly, it is unclear how catalyse work with other sectors and con- to clarify the different types of action effectively global targets can deal with such tribute to policies and interventions that are required: structural challenges. Global and national of core concern to other sectors but that can • Addressing structural forces and social strategies can draw from existing concep- be shaped to maximise positive health out- and gender norms that affect all of society, tual frameworks for determinants, such as comes. This requires building the capacity including those that drive disparities, that of the Commission on Social Determi- of the health sector to work with other which require wide ranging cross sectoral nants of Health,20 and recent adaptations, ­sectors and identify areas of mutual con- policies driven by heads of government such as for child wellbeing,21 to consider cern. Issues of governance, financing (and and championed by key societal agents of how implementation can account for these co-financing across sectors), implementa- change obstacles.

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2. Identifying key SDG targets for joint efforts at prioritisation (figure ).22 It excludes 4. Implementing multisectoral efforts tracking and action the priority SDG 3 health targets in which the Efforts to drive multisectoral action on deter- MDGs 4-6 strongly underpinned global and health sector will take the lead. Exceptions minants of health have often stalled at the national efforts on maternal and child health are targets 3.6 on road traffic injury and 3.9 implementation phase, even when policy and the SDGs aim to provide a similar plat- on pollution where non-health sectors need makers accept the rationale and conceptual form. RMNCAH is well represented by SDG 3 to lead. framework. Governance, financing, and joint (the “health goal”), with updated MDG 4-6 There is a need to mobilise efforts across monitoring of multisectoral action to achieve targets, new targets on non-communicable these targets and facilitate their joint moni- targets on RMNCAH have proved difficult in diseases and injuries, and on universal toring, along with the health outcome tar- practice. While the details of these problems health coverage, all of which require multi- gets, for accountability at country and global are often beyond the scope of global and sectoral efforts. level (for example, extending and expanding national strategies, they are fundamental to However, the SDGs will be more compre- the current Countdown to 2015 platform23). implementation. Different countries’ suc- hensive, with 17 goals and 169 targets pro- This is a clear avenue for EWEC 2.0 to make a cesses in driving multisectoral efforts to posed, encompassing a greater number of contribution. improve RMNCAH (table 2) provide useful sectors related to RMNCAH. This compre- guidance that merits greater dissemination, hensive scope implies a need to learn from 3. Prioritising key multisectoral including through South-South collabora- the fragmentation of sectors during the interventions, policies, and indicators for tion (direct collaboration and technical implementation of the MDGs, with goals action assistance between low and middle income identified with single sectors.17 Unintended Most global and national strategies on countries). risks of this comprehensiveness are dilution RMNCAH have highlighted key healthcare Specific guidance is needed on the work of efforts and a lack of focus on specific inter- interventions needed but not interventions and governance of different types of multi- ventions. This can be mitigated by prioritis- and policies led by other sectors. As global sectoral action (single sector, intersectoral, ing targets across different sectors to help and national strategies are updated to incor- and cross sectoral), including on how key focus global and national efforts to improve porate the SDGs (including EWEC 2.0), they policies for RMNCAH can be implemented RMNCAH. should include a guide to multisectoral and linked across sectors, even in low Almost all of the proposed goals have action on determinants, prioritising key pol- income, high burden settings. Lessons are some relevance to the determinants of icies and interventions, with indicators for available from the HIV movement’s RMNCAH. Difficult choices need to be made joint monitoring against the SDG targets. response, tobacco control, and the environ- about which targets are crucial. We drew up Table 1 lists initial proposals for key deter- mental sector. Building governance for a an initial priority list of targets for global and minants, interventions, policies, indicators, multisectoral approach can benefit from national strategies, drawn from a longer list and SDG targets to be prioritised as part of obligations under the human right to health, of potential targets and informed by other EWEC 2.0. which calls for healthcare and interventions

1.1 By  eradicate extreme poverty for all people everywhere, currently measured as living on less than .
a day

1.3 Implement nationally appropriate social protection systems and measures for all, including floors, and by  achieve substantial coverage of poor and vulnerable people

2.2 By  end all forms of malnutrition, including achieving the internationally agreed targets on stunting and wasting in children under
years of age by 
. Address the nutritional needs of adolescent girls, pregnant and lactating women, and older women

3.6 By  halve the number of global deaths and injuries from road trac accidents

3.9 By  substantially reduce the number of deaths and illnesses from hazardous chemicals and air, water and soil pollution and contamination

4.1 By  ensure that all girls and boys complete free, equitable, and quality primary and secondary education that leads to relevant and e­ective learning outcomes

4.2 By  ensure that all girls and boys have access to good quality early childhood development, care, and pre-primary education so that they are ready for primary education

5.1 End all forms of discrimination against all women and girls everywhere

5.2 Eliminate all forms of violence against all women and girls in public and private spheres, including tracking and sexual and other types of exploitation

5.3 Eliminate all harmful practices, such as child, early and forced marriage, and female genital mutilation

5.5 Ensure women’s full and e­ective participation and equal opportunities for leadership at all levels of decision making in political, economic, and public life

5.6 Ensure universal access to sexual and reproductive health and reproductive rights as agreed in accordance with the Programme of Action of the International Conference on Population and Development and the Beijing Platform for Action and the outcome documents of their review conferences

6.1 By  achieve universal and equitable access to safe and a­ordable drinking water for all

6.2 By  achieve access to adequate and equitable sanitation and hygiene for all, and end open defecation, paying special attention to the needs of women and girls and those in vulnerable situations

7.1 By  ensure universal access to a­ordable, reliable, and modern energy services

13.2 Integrate climate change measures into national policies, strategies, and planning

16.2 End abuse, exploitation, tracking, and all forms of violence against and torture of children

16.9 By  provide legal identity for all including birth registration

17.18 By  enhance capacity building support to developing countries, including for least developed countries and small island developing states, to increase signiˆcantly the availability of high quality, timely, and reliable data disaggregated by income, gender, age, race, ethnicity, migratory status, disability, geographical location, and other characteristics relevant in national contexts

Priority sustainable development goal targets for reproductive, maternal, newborn, child, and adolescent health

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Table 1 | Key reproductive, maternal, newborn, child, and adolescent health determinants; interventions; indicators; and corresponding sustainable development goal (SDG) targets Determinant Policies and interventions Indicator SDG targets* Income and social Reduce poverty through the use of child and gender sensitive Proportion of population below $1.25†/day 1.1, 5.4 protection cash transfer programmes designed with health sector input, disaggregated by sex and age group especially on use of conditionality Food security Prioritise measures to enhance food security in communities with Prevalence of undernourishment 2.1 high mortality burden Nutrition in infants and Implement Infant and Young Child Feeding (IYCF) guidelines Prevalence of stunting in children under 5 years of age; 2.2 young children rate of exclusive breast feeding among infants under 6 months of age Education of adolescent Prioritise support for adolescent girls to receive a good quality Completion rate (%) of upper secondary education by 4.1 girls education, including through mechanisms such as cash transfers girls Early child development Implement a multisectoral approach to early child development Early Childhood Development Index 4.2 for all children, using a progressive universalism approach to maximise gains for the worst off Ending child marriage Enact legislation and provide social support services to end child Proportion of women aged 20-24 who were married or 5.3 marriage in a union before age 18 years Ending violence against Enact legal frameworks criminalising all forms of violence and Proportion of ever partnered women and girls (aged 5.2 women and children abuse against women and children 15-49) subjected to physical or sexual violence (or both) by a current or former intimate partner in the past 12 months Proportion of young adults aged 18-24 years who have 16.2 experienced violence by age 18, by type (physical, psychological, or sexual) Political participation of Implement minimum quotas for participation of women in Proportion of seats held by women in local governments 5.5 women political institutions, such as parliaments Safe drinking water Provide universal access to safely managed, affordable, and Proportion of population using safely managed drinking 6.1 sustainable drinking water through investments in education on water services the importance of safely managed water use and infrastructure in households, communities, schools, and health facilities Access to improved End open defecation and provide universal access to improved Proportion of population using safely managed 6.2 sanitation and hygiene sanitation facilities and hygiene measures, and encourage sanitation services implementation of sanitation safety plans Access to electricity Prioritise new infrastructural development for energy access in Proportion of population with electricity access 7.1 communities with high mortality burden, including in health facilities Exposure to household air Increase use of clean home energy fuels and technologies (for Proportion of people using primarily clean fuels or 7.1 pollution cooking, heating, lighting) technologies (for cooking, heating, lighting), where “clean” is defined by WHO guidelines Child mortality and morbidity attributable to household 3.9 air pollution Hazardous child labour Systematic detection and elimination of hazardous child labour Proportion and number of children aged 5-17 years 8.7 engaged in child labour, by sex and age group (disaggregated by the worst forms of child labour) Lead in the environment Eliminate non-essential uses of lead (such as in paint) and ensure Number of countries that have regulated lead in paint 12.4 the safe recycling of waste that contains lead Climate change Enhance climate resilience of environmental determinants of Population coverage with climate resilient infrastructure 13.2 health (such as climate resilient water, sanitation, and hygiene and management practices (such as climate resilient infrastructure and management practice) water safety plans) Birth registration Build civil registration and vital statistics systems to achieve Proportion of children under 5 whose births have been 16.9 universal birth and death registration registered with civil authority *See figure. †Purchasing power parity.

on the “underlying” determinants, provid- RMNCAH. All countries already invest nutrition, water, and sanitation—to deliver ing a legal and normative framework for resources on determinants as part of core joint information and accountability and tackling determinants.3 work in other sectors. The question is allow cross sectoral analysis and prioritisa- Tools and methods are available for ana- whether EWEC 2.0, and its follow-up, can tion for investment and implementation at lysing health risks and benefits associated accelerate investment in a set of key policies country level. Disaggregating data for indi- with policies implemented across and within and interventions on determinants. Discus- cators for interventions in health and non- different sectors (such as “health in all poli- sions on single national investment plans health sectors would facilitate a greater cies” and health impact assessment) and to have already identified key areas where non- focus on equity and reinforce attention on review specific determinants (such as gender health sector interventions are crucial for determinants, given that drivers of disparity assessments and audits and gender respon- RMNCAH outcomes.26 lie mostly beyond the health sector. sive planning and budgeting).24 25 The Global and national RMNCAH strategies Evidence gaps on determinants remain to engagement of women, children, and ado- (particularly EWEC 2.0 at the global level) be filled, mostly by implementation lescents in decisions about their own health should monitor key determinants and inter- research. For example, evidence on the should be prioritised when designing new ventions beyond the health sector as part of health impacts of specific interventions governance structures, measurement tools, their accountability follow-up, harnessing within sectors and on interventions and pol- standards, and policies. existing monitoring initiatives in other sec- icies to address societal or structural forces EWEC 2.0 should aim to mobilise financial tors. Global reports on RMNCAH need to be is sparse, whereas evidence on interventions resources for action on determinants of linked with efforts in other sectors—such as for social protection and environmental

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Table 2 | Examples of successful multisectoral interventions on determinants of reproductive, maternal, newborn, child, and adolescent health Country Determinant Action Impact Peru Malnutrition in children “Buen Inicio”—a package of community based Reduction in child stunting and anaemia in pilot communities; under 3 and in pregnant interventions including health promotion by rural foundation for national strategy to combat child malnutrition and lactating women trained health promoters, hygiene, and antenatal care Rwanda Governance and sex Biannual joint health sector reviews and Passage of bill to reduce gender based violence; highest global equality establishment of health sector working groups; rates of female parliament participation; planned programme of creation of the Rwanda Women Parliamentarian health sector decentralisation Forum and the Women’s Council Zimbabwe Sex equality and girls’ Efforts to increase girls’ participation in school 75% of women aged 15-24 completed lower secondary school in education 2010; HIV prevalence decreased from 29% in 1997 to 14% by 2007 Malawi Girls’ education Randomised controlled trial provided conditional cash Reduction in teenage pregnancies (29%) and early marriage transfers ($1-$15*/month) to 1200 women aged 13-22 (32%); prevalence of HIV infection fell by 64% and their parents while also paying school fees Uganda Sex based violence Collaborative SASA! study aimed at reducing sex 52% lower rates of sex based violence and fewer concurrent based violence by implementing a violence prevention sexual partners among men in SASA! communities versus intervention in eight communities in Kampala; controls; sex based violence believed to be less acceptable and qualitative data on social change also collected the idea that women can refuse sex more acceptable in SASA! communities Niger Early marriage and fertility Creating safe spaces for adolescent women to interact Increased sexual and reproductive health knowledge among with trained female mentors; community dialogue; adolescent women; increased ability to read the alphabet, nearly home visits by mentors; health check-ups, literacy and 100% of females set up a savings plan; girls believe they have the numeracy training for girls; sexual and reproductive right to choose their spouse and programme is overall acceptable health promotion Mozambique Information and Community based, multisectoral project in which Increased credibility among community health volunteers, communication community health volunteers improve community use stronger linkages to health system, and expedited management of technologies of maternal, newborn, and child health services minor and major health complications through community engagement and mobile phones to follow pregnant women through pregnancy; reminders and advice provided through text or audio messages; made antenatal and postpartum visits New Zealand Poor housing Insulation and thermal envelope improvements in Reduced self reported respiratory illness, doctor visits, hospital 1350 low income households admissions, and days off work or school; marginal increase in indoor temperatures but 13% reduction in energy use; health gains cost effective compared with carbon dioxide mitigation *$1=£0.64; €0.91.

determinants is more robust. Evidence of increase understanding of their health gains to increased uptake of specific interventions multisectoral impact is scattered and often and of the value of “co-benefits” shared within sectors but mark a paradigm shift in drawn from modelling exercises, which between health and other sectors. the organisation of societies. A multidisci- assess correlation but do not provide specific plinary and multi-institutional approach evidence on the mechanisms that directly Limitations with new participatory processes is needed improve health. Tools used in RMNCAH The above four areas are first steps in a full to realise the full vision of the SDGs. planning and budgeting (such as the lives determinants approach to RMNCAH. This We did not cover the two way associa- saved tool27 28) should encompass interven- approach may seem “selective,” missing the tion and contribution of health to other tions beyond the health sector, but this will complexity and comprehensiveness sectors because of the abundance of litera- require improving the evidence base. The required. The ambitious visions of initiatives ture in this area. For example, it has been generation of costing and effectiveness data such as the UN Commission on Sustainable estimated that increases in health expen- for key interventions and policies for Development and the WHO Commission on diture in high burden countries would RMNCAH outside of the health sector would Social Determinants of Health are not limited­ have enormous economic and social bene- fits,29 and that about 24% of recent full income growth in low and middle income 30 Box 2: Key global activities to support multisectoral action on determinants of countries came from health gains. The reproductive, maternal, newborn, child and adolescent health (RMNCAH) association between determinants and individual agency, capability, and oppor- 1. Joint global and national monitoring of interventions and targets (table 1) driven by the 31 32 United Nations secretary general’s office, building on existing sectoral monitoring efforts and tunities is also complex, and further incorporating a gender sensitive lens work on the drivers of behaviour is war- 2. Efforts to synthesise and generate data on the cost and effectiveness of key RMNCAH outcomes ranted, including social and cultural of multisectoral interventions and policies norms—for example, their role in perpetu- 3. Efforts to synthesise and build knowledge on incentives for intersectoral action, including how ating gender inequality, racism, and other joint efforts can drive mutual benefits for RMNCAH and the core business of other sectors forms of discrimination. 4. Mobilise the Every Woman Every Child movement, in particular governments and civil society We acknowledge these limitations and do (including faith based organisations), to invest in champions (such as parliamentarians) and not imply that these broader questions can institutions to steer multisectoral action on determinants be ignored. Instead, the areas highlighted 5. Mobilise financing and incentivise multisectoral collaboration and action through existing represent practical starting points in moving partnerships and new financing mechanisms efforts on RMNCAH beyond the health sector 6. Consider how the Every Woman Every Child innovation pipeline can contribute further to to tackle determinants, with the hope that 33 multisectoral action follow-up work can engage with these 7. Request the United Nations to coordinate, as appropriate, the work needed between sectors, greater complexities, which are particularly including setting an example by better coordination within itself important for reducing disparities.

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Conclusion Azza Karam senior adviser1, 6 13 Legge D, Sanders D. New development goals must focus on social determinants of health. BMJ Shyama Kuruvilla senior strategic adviser1, 7 The launch of the SDGs and the 2016-2030 2013;346:f1893. Global Strategy for Women’s, Children’s and Jacqueline Mahon senior policy adviser1, 6 14 Ottersen OP, Dasgupta J, Blouin C, et al. The political Maria Neira director 1, 4 origins of health inequity: prospects for change. Lancet Adolescents’ Health provides an opportunity 2014;383:630-67. to “mainstream” multisectoral efforts on Eugenio Villar Montesinos coordinator1, 8 15 Buse K, Hawkes S. Health in the sustainable improving determinants of RMNCAH at Deborah von Zinkernagel director 1, 9 development goals: ready for a paradigm shift? Glob Health 2015;11:13. 1, 10 global, national, and district levels. Import- Douglas Webb cluster leader 16 Partnership for Maternal, Newborn and Child Health, ant first steps are to clarify how multisectoral 1Every Woman Every Child Determinants of Health WHO. A policy guide for implementing essential interventions for reproductive, maternal, newborn and efforts on determinants fit into post-2015 Working Group, Health Section, Unicef, New York 10017, USA child Health (RMNCH): a multisectoral policy efforts on improving RMNCAH; prioritise key compendium for RMNCH. 2014. www.who.int/pmnch/ 2Health Section, Unicef, New York determinants, interventions, policies, indi- knowledge/publications/policy_compendium.pdf. 3United Nations Women, New York 17 WHO, Unicef, Government of Sweden and Government cators, and SDG targets; and build the gover- 4Department of Public Health, Social and Environmental of Botswana. Health in the post-2015 agenda. Report of the global thematic consultation on health. 2013. nance, financing, monitoring, and research Determinants of Health, World Health Organization, www.worldwewant2015.org/file/337378/ needed for implementation. Box 2 sum- Geneva, Switzerland download/366802. marises key activities at the global level, but 5Norad, Oslo, Norway 18 WHO, Unicef. Water, sanitation and hygiene in health 6United Nations Population Fund, New York care facilities: status in low- and middle-income the extent to which national strategies and countries and way forward. 2015 www.who.int/ implementation policies reorient their 7Cluster of Family and Community Health, WHO, Geneva water_sanitation_health/publications/wash-health- efforts to integrate a multisectoral focus on 8Social Determinants of Health Unit, WHO, Geneva care-facilities/en. 9 19 WHO. Education: shared interests in well-being and determinants of RMNCAH, informed by UNAIDS, Geneva development. Social determinants of health sectoral EWEC 2.0, will be more important. To sup- 10United Nations Development Programme, New York briefing series 2. 2011. http://whqlibdoc.who.int/ publications/2011/9789241502498_eng.pdf?ua 1. Correspondence to: K Rasanathan [email protected] = port these efforts, we propose a UN commis- 20 Solar O, Irwin A. A conceptual framework for action on sion on implementation and accountability 1 United Nations. Global strategy for women’s the social determinants of health. Social determinants and children’s health. 2010. www.who.int/pmnch/ of multisectoral action for women’s, chil- of health discussion paper 2 (policy and practice). activities/advocacy/fulldocument_globalstrategy/en. WHO. 2010. http://whqlibdoc.who.int/ dren’s, and adolescents’ health. Similar to 2 Commission on Social Determinants of Health. Closing publications/2010/9789241500852_eng.pdf. the Commission on Information and the gap in a generation: health equity through action 21 Banati P, Alexander G, Expert working group on on the social determinants of health. Final report. structural determinants of child wellbeing. The Accountability for Women’s and Children’s 2008. www.who.int/social_determinants/ structural determinants of child wellbeing. Unicef, Health, this should collect available knowl- thecommission/finalreport/en. 2012. www.unicef-irc.org/publications/pdf/ 3 Committee on Economic, Social and Cultural Rights. edge and put in place a multisectoral focus structural_determ_eng.pdf. Substantive issues arising in the implementation of the 22 Silver KL, Singer PA. SDGs: start with maternal, newborn, on improving determinants of RMNCAH at ICESCR: general comment no 14: the right to the and child health cluster. Lancet 2014;384:1093-4. global and national levels. highest attainable standard of health (article 12 of the 23 Requejo JH, Bryce J, Barros AJD, et al. Countdown to ICESCR). United Nations Economic and Social Council, 2015 and beyond: fulfilling the health agenda for This article has benefited from comments and 2000. http://data.unaids.org/publications/ women and children. Lancet 2015;385:466-76. suggestions from several colleagues, including Heather external-documents/ecosoc_cescr-gc14_en.pdf. 24 Kickbusch I. Health in all policies: the evolution of the Adair Rohani, Yarlini Balarajan, Ruth Bell, Simon Bland, 4 Women and Gender Equity Knowledge Network. concept of horizontal health governance. In: Kickbusch Sophie Boisson, Diarmid Campbell-Lendrum, Unequal, unfair, ineffective and inefficient. Gender I, Buckett K, eds. Implementing health in all policies. Bernadette Daelmans, Dmitri Davydov, Theresa Diaz, inequity in health: why it exists and how we can change Department of Health, Government of South Australia, Peter Drury, Sharon Friel, Ivan Ivanov, Jonas Karlstrom, it. WHO, 2007 www.who.int/social_determinants/ 2010:11-23. Rajat Khosla, Laura Laski, Don Matheson, Margaret resources/csdh_media/wgekn_final_report_07. 25 WHO. Health in all policies: training manual. 2015. www. Montgomery, Lesley Onyon, Payden, Maria Perez, pdf?ua=1. who.int/life-course/news/health-in-all-policies/en. Michaela Pfeiffer, Arletty Pinel, Jennifer Rasanathan, 5 Kuruvilla S, Schweitzer J, Bishai D, et al, on behalf of the 26 World Bank. Global financing facility in support of Every Success Factors for Women’s and Children’s Health Nathalie Roebbel, Victoria Saint, Julian Schweitzer, Woman, Every Child. 2014. www.worldbank.org/ study groups. Success factors for reducing maternal content/dam/Worldbank/document/HDN/Health/ Marleen Temmerman, Joanna Tempowski, Nicole and child mortality. Bull World Health Organ Valentine, and Emilie Van Deventer. Inputs received GFFExecutiveSummaryFINAL.pdf . 2014;92:533-44. 27 Victora CG. LiST: using epidemiology to guide child during sessions at the global stakeholder consultation 6 Wang H, Liddell CA, Coates MM, et al. Global, regional, survival policymaking and programming. Int J held on 26-27 February 2015 in Delhi, India, and during and national levels of neonatal, infant, and under-5 Epidemiol 2010;39:650-2. the online public consultation in March-April 2015 on mortality during 1990-2013: a systematic analysis for 28 Fox MJ, Martorell R, van den Broek N, et al. an earlier draft are also gratefully acknowledged, along the Global Burden of Disease Study 2013. Lancet Assumptions and methods in the lives saved with the constructive comments from the journal editors 2014;384:957-79. tool (LiST). Introduction. BMC Public Health and peer reviewers. 7 Gakidou E, Cowling K, Lozano R, et al. Increased 2011;11(suppl 3):I1. Contributors: All authors conceived the article. KR wrote educational attainment and its effect on child mortality 29 Stenberg K, Axelson H, Sheehan P, et al. Study Group in 175 countries between 1970 and 2009: a systematic the first draft. All authors contributed to the article. KR is for the Global Investment Framework for Women’s analysis. Lancet 2010;376:959-74. guarantor. Children’s Health. Advancing social and economic 8 Black RE, Victora CG, Walker SP, et al. Maternal development by investing in women’s and children’s Competing interests: We have read and understood and child undernutrition and overweight in health: a new global investment framework. Lancet BMJ policy on declaration of interests and have no low-income and middle-income countries. Lancet 2014;383:1333-54. relevant interests to declare. 2013;382:427-51. 30 Jamison DT, Summers LH, Alleyne G, et al. Global health 9 Prüss-Üstün A, Corvalán C. Preventing disease through The authors alone are responsible for the views 2035: a world converging within a generation. Lancet healthy environments: towards an estimate of the expressed in this article, which does not necessarily 2013;382:1898-955. environmental burden of disease. WHO, 2006. www. 31 Bircher J, Kuruvilla S. Defining health by addressing represent the views, decisions, or policies of the who.int/quantifying_ehimpacts/publications/ institutions with which the authors are affiliated. individual, social, and environmental determinants: preventingdisease.pdf. new opportunities for health care and public health. Provenance and peer review: Not commissioned; 10 Cohen RL, Alfonso YN, Adam T, et al. Country progress J Public Health Policy 2014;35:363-86. externally peer reviewed. towards the millennium development goals: adjusting 32 Robeyns I. The capability approach. Stanford for socioeconomic factors reveals greater progress and Kumanan Rasanathan senior health specialist1, 2 Encyclopedia of Philosophy (summer 2011 ed). 2011. new challenges. Glob Health 2014;10:67. http://plato.stanford.edu/archives/sum2011/entries/ 1, 3 Nazneen Damji policy adviser 11 Unicef. The investment case for education and equity. capability-approach. Tesmerelna Atsbeha programme specialist1, 3 2015. www.unicef.org/publications/files/Investment_ 33 El-Noush H, Silver KL, Pamba AO, et al. Innovations for Case_for_Education_and_Equity_FINAL.pdf. women’s, children’s, and adolescents’ health. BMJ Marie-Noel Brune Drisse technical officer1, 4 12 Verguet S, Jamison DT. Estimates of performance in the 2015;351:h4151. Austen Davis senior adviser1, 5 rate of decline of under-five mortality for 113 low- and middle-income countries, 1970-2010. Health Policy Carlos Dora coordinator1, 4 Plan 2014;29:151-63. Cite this as: BMJ 2015;351:h4213

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Human rights in the new Global Strategy By recognising the centrality of human rights, the revised Global Strategy encourages some bold shifts in improving the health and wellbeing of women, children, and adolescents, say Jyoti Sanghera and colleagues

he Global Strategy for Women’s and of non-discrimination.1 Health facilities, Lack of autonomy, agency, and economic Children’s Health (2010), with its goods, and services must also be acceptable— independence affects the ability of women to emphasis on participatory decision that is, gender and child sensitive and respect- access health services or to interact with making processes, non-discrimina- ful of confidentiality and the requirement health systems in ways that respect their tion, and accountability, affirmed for informed consent, among other things. rights to privacy and confidentiality, which in theT importance of human rights. Despite A human rights based approach is based turn may inhibit them from seeking these ser- important gains following its launch women, on accountability and on empowering vices. This is, arguably, most evident in the children, and adolescents continue to expe- women, children, and adolescents to claim area of reproductive and sexual health, where rience serious violations of their health and their rights and participate in decision mak- maternal mortality and morbidity rates health related human rights, including dis- ing, and it covers the interrelated determi- remain high.2 The health situation of the most crimination in access to quality healthcare. nants of health and wellbeing (box). Because marginalised groups of women and girls, A human rights based approach must thus a human rights based approach promotes including those belonging to sexual minori- be fully integrated throughout the Global holistic responses, rather than fragmented ties, ethnic minorities, and rural communities Strategy. strategies, and requires attention to the and women and girls with disabilities, is The right to health is recognised by sev- health needs of marginalised and vulnerable especially acute in all of the above respects. eral legal tools and treaties relating to populations, it is a valuable tool for improv- human rights, including the International ing health outcomes. Children Covenant on Economic, Social and Cultural States have an obligation, under human Rights; the Convention on the Rights of the Methods rights law, to take measures to protect the Child; and the Convention on the Elimina- The methods we used in this article comprise right of the child to life and to ensure his or tion of All Forms of Discrimination against reference to existing human rights norms her survival and development.3 One major Women. A human rights framework for real- documented in relevant legal texts, as inter- challenge to reducing ill health in children is ising the right to health of women, children, preted by authoritative guidance and expert the failure to systematically identify and and adolescents calls for national govern- opinion. We drew our recommendations on overcome the root causes. These include the ments to ensure that health facilities, goods, the basis of the need for health laws and denial of the right to adequate water, sanita- and services are of good quality, are avail- practices to conform to human rights stan- tion, and hygiene; malnutrition; the failure able in sufficient­ quantity, and are physi- dards, a need identified by common and well to provide safe and secure living environ- cally accessible and affordable on the basis known trends in government policy and ments; harmful practices; and discrimina- practice. tion. All of these have an effect on the ability Key messages to enjoy good health and to access good Human rights problems quality healthcare.4 In addition, young chil- Unless human rights are integrated Many of the barriers faced by women, chil- dren are often victims of neglect, maltreat- throughout the Global Strategy for dren, and adolescents in accessing health- ment, and abuse; their inability to protect Women’s, Children’s and Adolescents’ care and other entitlements and services themselves or to seek the protection of others Health, the health and health related rights that affect their ability to live healthy lives renders them particularly at risk. of these groups will not be fully realised are a consequence of the denial of human Respect for the status of children as rights Despite important gains women, children, rights. holders and for their agency is a pre-condi- and adolescents continue to experience tion for the full exercise of their health and serious violations of their health and Women and girls health related rights. This is often ignored or health related human rights Laws, policies, and practices often discrimi- rejected owing to conceptions about age and Insufficient attention to discrimination and nate against women and girls, resulting in immaturity, as well as to cultural norms gov- social exclusion in policy development and the denial of autonomy and agency and in erning the child’s role in the family and service provision consistently undermine differential access to healthcare. Gender ste- broader society.5 The failure to ensure that efforts to ensure and improve access to reotypes and discrimination against women the best interests of the child are assessed and quality of care and girls often result in the perpetuation of and taken as a primary consideration in all Health is a justiciable human right that harmful practices such as early, childhood, actions affecting children is also implicated is interdependent with and indivisible or forced marriage; gender based violence; in poor responses to child health,6 as is the from other human rights, including the female genital mutilation; neglect; and violation of the right of children to express rights to life, bodily integrity, autonomy, infanticide. Although laws and policies have their views and to have these views seriously information, and privacy been put in place to prevent these practices, taken into account, according to age and Key interventions in the area of policy prevailing social norms continue to play an maturity.7 This is true to an even greater and legislation, equality and non- important part in confining women to the extent for marginalised or vulnerable groups discrimination, service delivery, stakeholder role of mothers and caregivers and limiting of children, such as children with disabili- participation, the underlying determinants access to education, paid employment, and ties, children affected by HIV/AIDS, migrant of health, and accountability are proposed equal opportunities. children, children in detention, and child

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criminalise specific sexual and reproduc- Human rights add value tive conduct and decisions, such as abor- To meet their obligation to respect, fulfil, and protect the right to health and other health rights guaranteed under international human rights law, governments can adopt a human rights based tion, same sex intimacy, and sex work. approach by: – Enact laws and implement policies promot- • Providing access to affordable, acceptable, and good quality healthcare and services for all women, ing positive measures to ensure that children, and adolescents on an equal footing essential health services, including pri- • Empowering women, children, and adolescents to claim their rights and participate in decision mary healthcare, sexual and reproductive making health services, maternal health services, • Putting in place the necessary policy and legal frameworks to ensure the accountability of all actors and neonatal, child, and adolescent involved in health service delivery health services are available, accessible, • Adopting comprehensive strategies, working together with other sectors that affect health, to respond acceptable, and of good quality. to the full range of health challenges faced by women, children, and adolescents – Prohibit harmful practices such as early, • Engaging multiple stakeholders, including children and adolescents, in policy formulation, forced, or childhood marriage; female implementation, and review and supporting their consistent participation genital mutilation; and violence against • Improving health outcomes for marginalised, excluded, and vulnerable women, children, and women, children, and adolescents, adolescents including gender based violence. – Promote social mobilisation, education, refugees and internally displaced people. In Response and priority interventions information, and awareness raising pro- much the same way that early childhood Below we set out the priority human rights grammes and campaigns to challenge dis- development profoundly affects health interventions to advance the health and crimination and harmful social norms and throughout life, the poor realisation of rights health related rights of women, children, to create legal awareness and literacy in childhood frequently determines the and adolescents. Although not exhaustive, among health service personnel and ben- enjoyment of rights in later life.8 9 these interventions would, if implemented, eficiaries, with a focus on women, chil- help to overcome major obstacles to the real- dren, and adolescents, including Adolescents isation of these rights and, through that, pro- vulnerable and marginalised groups Whereas maternal and child mortality and vide solutions to many of the health within these populations. morbidity have received increasing atten- challenges. The web appendix expands on tion, adolescent health has not benefited to the interventions under each heading. Participation the same extent despite the fact, for The meaningful participation of all women, instance, that the highest rate of maternal Enabling policy and legal environment children, and adolescents, including those deaths is among adolescent girls.10 Adoles- Laws and policies have a direct bearing on from marginalised or vulnerable groups, in cence is an important developmental stage the realisation of health and human rights by the formulation, implementation, and mon- presenting particular challenges for health women, children, and adolescents, so an itoring of policies that affect their health is and wellbeing. From puberty, the risks asso- enabling legal and policy environment is an essential building block of a human ciated with sexual violence, childhood and indispensable. Legislative and policy inter- rights based approach. Priority interventions early marriage, unwanted pregnancy, mater- ventions should be geared towards the enact- should be to: nal mortality and morbidity, and the inci- ment, amendment, or repeal of laws and – Build the capacity of rights holders to par- dence of HIV and other sexually transmitted policies, as necessary, to align legal and pol- ticipate and to claim their rights, through infections increase exponentially. Proactive icy frameworks with human rights norms.11 12 education and awareness raising, and measures are needed to ensure that risks are Priority interventions should be to: ensure that transparent and accessible averted and that these early years lay down mechanisms for engaging stakeholders’ strong foundations for a healthy life. – Collect comprehensive data disaggregated participation and facilitating regular com- Adolescents face considerable barriers by sex, age, disability, race, ethnicity, munication between rights holders and in accessing high quality healthcare and mobility, or economic or other status, as health service providers are established services, particularly sexual and reproduc- nationally relevant, to identify women, and/or strengthened at community, tive health services and information, that children, and adolescents facing discrimi- sub-national, and national levels. respond to their needs and their evolving nation in access to healthcare and other – Ensure stakeholders’ participation in prior- capacities. Access to sexual and reproduc- entitlements and services that affect their ity setting; in policy and programme tive health services and information is health and related human rights. design, implementation, monitoring, and often hindered as a result of laws and reg- – Conduct an assessment of the extent to evaluation; and in accountability mecha- ulations imposing restrictions relating to which existing legal and policy frame- nisms. This can be achieved by establish- minimum age, third party authorisation, works comply with the human rights ing and/or strengthening transparent or marital status. Policies that allow health norms applicable to health and wellbeing, participation and social dialogue or service providers to deny women sexual as part of a comprehensive analysis, multi-stakeholder mechanisms at commu- and reproductive health services on the through a participatory, inclusive, and nity, sub-national, and national levels and basis of their religious beliefs while simul- transparent process, with stakeholder ensuring that participation outcomes taneously failing to ensure alternative consultation throughout. inform sub-national, national, and global access to these services, negative and – Repeal, rescind, or amend laws and poli- policies and programmes related to wom- ­discriminatory attitudes grounded in per- cies that create barriers or restrict access en’s, children’s, and adolescents’ health.13 sonal beliefs regarding adolescent sexual- to health services and that discriminate, ity, and cultural norms can all be major explicitly or in effect, against women, chil- factors preventing or inhibiting access to dren, and adolescents as such or on Equality and non-discrimination sexual and reproductive health services grounds prohibited under human rights Discrimination on grounds prohibited under and information. law. This includes the repeal of laws that international human rights law, including

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on account of gender, age, race, ethnicity, to high quality and affordable healthcare and the justice systems.24 These include income, and location, severely undermines for diseases affecting women, children, courts or quasi-judicial and non-judicial the enjoyment of human rights. Priority and adolescents, in an environment that bodies, complaints mechanisms within interventions should be to: guarantees free and informed decision the health system, national human rights making and respect for privacy, autonomy, institutions, and professional standards – Develop, fund, and implement a national and agency. Health information, counsel- associations. strategy to eliminate discrimination against ling, and education should be evidence – Develop a national strategy to promote women, children, and adolescents in based, in line with human rights, and access to justice mechanisms for women, access to health services and in health- readily available and accessible to women children, and adolescents. Measures care, taking into account, particularly, and adolescents as well as children, in include identifying and removing barriers gender and age based discrimination. accordance with their level of maturity. to access, such as cost, through the provi- – Tackle the specific barriers faced by – Provide for universal access to health cov- sion of free legal assistance, the establish- women, children, and adolescents from erage for all women, children, and adoles- ment of mobile courts or other redress marginalised and vulnerable population cents, including those from marginalised mechanisms to facilitate physical access, groups—for example, through the provi- or vulnerable populations and those and ensuring that services are available in sion of culturally appropriate health ser- employed in the informal sector. Coverage languages that are understood by the cli- vices for indigenous peoples, the provision should identify the priority interventions ent communities.25 of health information in formats that are guaranteed, and services should be free at accessible to people with disabilities, and the point of access to ensure the protec- Conclusion health coverage for both documented and tion of privacy and confidentiality. Most barriers to access to healthcare facing undocumented migrant populations. – Provide comprehensive training on the women, children, and adolescents can, health rights of women, children, and arguably, be attributed to the failure to inte- Planning and budgeting adolescents; the effect of discrimination; grate human rights into health law and pol- States have an obligation to take steps to and the importance of communication icy and to tackle violations of the right to achieve the progressive realisation of the and respect for patients’ dignity in health- health. The Global Strategy presents a valu- right to health of women, children, and ado- care settings. This should be an integral able opportunity to reduce deficits in imple- lescents to the maximum of their available part of all training for health personnel. menting a human rights based approach to resources.14 15 Priority should be given to the health of women, children, and adoles- securing adequate funding for the health Structural and other determinants of cents by mobilising national efforts to this and health related sectors and to implement- health end. The human rights interventions pro- ing comprehensive strategies and plans of The right to health encompasses access both posed in this paper aim to respond to the action.16 Priority interventions should be to: to healthcare and to other factors affecting common areas in which national implemen- health such as adequate nutrition, housing, tation tends to be weak and to focus atten- – Formulate comprehensive, rights based, water, sanitation, and hygiene.20 21 A human tion on where the most significant gains coordinated, multi-sectoral strategies and rights based approach to women’s, chil- potentially stand to be made. adequately resourced plans of action man- dren’s, and adolescents’ health requires a The human rights sub-work stream is composed of dating action to ensure the accessibility, multifaceted, multisectoral approach to the following members in addition to those named availability, acceptability, and quality of improve the determinants of health and as authors of this paper: Janette Amer (UN Women), facilities, goods, and services, without dis- Francesco Aureli (Save the Children), Paulos Berglof (UN ensure the full realisation of the right to Women), Rachel Brown (Centre for Reproductive crimination, and to reduce barriers to health and related rights. A review of the Rights), Antonio Cisneros (UNDG), Jarrod Clyne access.17 18 Plans of action should include determinants of health, together with pro- (Permanent Mission of New Zealand to the United targets and indicators prioritised through Nations Office and other international organisations in posed interventions, is available in the arti- a participatory and inclusive process and Geneva), Jashodhara Dasgupta (SAHAYOG), Emilie cle entitled “Socioeconomic,­ political, and Filmer-Wilson (UNDG), Stefan Germann (World Vision should focus attention on the health needs environmental determinants,” also pub- International), Cristina Gonzalez (Permanent Mission of the Eastern Republic of Uruguay to the United Nations of women, children, and adolescents. 22 lished as part of this series. Office and other international organisations in Geneva), – Establish participatory budget processes Shyama Kuruvilla (WHO), Breda Lee (Permanent Mission with a view to ensuring transparency and Accountability of Ireland to the United Nations Office and other promoting the involvement of women, international organisations in Geneva), Thiago Luchesi A human rights based approach requires children, and adolescents in monitoring (Save the Children), Esther Major (Amnesty strong accountability mechanisms that International), Ida Krogh Mikkelsen (UNFPA), Nicolette the allocation and utilisation of resources include redress, remedial action, and guar- Moodie (UNICEF), Mitra Motlagh (UNICEF), Sandeep for their health.19 Prasad (Action Canada for Sexual Health and Rights), antees of non-repetition. Effective account- Sarah Rattray (UNDP), Neha Sood (Action Canada for ability at country level involves a diverse Sexual Health and Rights), Marleen Temmerman (WHO), Rights based services range of actors within and beyond the health Jaime Todd-Gher (Amnesty International), and Rada Tzaneva (Amnesty International). Interventions in this area are those aimed at sector and requires multiple forms of review Contributors and sources: This article was the ensuring that health facilities, goods, and and oversight, including administrative, collaborative work of the human rights sub-work stream services are of good quality, are available in political, legal, and international account- of the Global Strategy on Women’s, Children’s and sufficient quantity, and are physically ability.23 Priority interventions should be to: Adolescents’ Health, with major text contributed by all the authors. LG integrated feedback from the sub-work accessible and affordable on the basis of stream as well as various consultations with experts in non-discrimination. Priority interventions – Establish and/or strengthen transparent, the area of women’s, children’s, and adolescents’ health should be to: inclusive, and participatory processes and and rights; she is the guarantor. mechanisms, with jurisdiction to recom- Competing interests: We have read and understood BMJ policy on declaration of interests and have no – Implement comprehensive strategies, for- mend remedial action, for independent relevant interests to declare. mulated through consultative processes accountability at the national, regional, Provenance and peer review: Not commissioned; and user participation, for ensuring access and global level within both the health externally peer reviewed.

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The authors alone are responsible for the views 4 Office of the United Nations High Commissioner for Human 16 Office of the United Nations High Commissioner expressed in this article, which does not necessarily Rights, World Health Organization. Technical guidance on for Human Rights, World Health Organization. represent the views, decisions, or policies of WHO or the the application of a human rights based approach to the Technical guidance on the application of a human institutions with which the authors are affiliated. implementation of policies and programmes to reduce and rights-based approach to the implementation of eliminate preventable mortality and morbidity of children policies and programmes to reduce preventable 1 Jyoti Sanghera chief under 5 years of age. UN, 2014; para 21. maternal morbidity and mortality. UN, 2012; Lynn Gentile human rights officer1 5 United Nations Committee on the Rights of the Child. para 26. 3 General comment No 7: implementing child rights in 17 United Nations Committee on the Rights of the Child. Alfonso Barragues technical adviser on human rights early childhood. UN, 2005; para 14. General comment No 7: implementing child rights in Imma Guerras-Delgado child rights adviser1 6 United Nations Committee on the Rights of the Child. early childhood. UN, 2005; para 22. General comment No 15: the right of the child to the highest 18 Office of the United Nations High Commissioner Lucinda O’Hanlon women’s rights adviser2 attainable standard of health. UN, 2013; para 12 and 19. for Human Rights, World Health Organization. Rachel Louise Hinton technical officer4 7 United Nations Committee on the Rights of the Technical guidance on the application of a human Kumanan Rasanathan senior health specialist6 Child. General comment No 14: the right of the child rights-based approach to the implementation of to have his or her best interests taken as a primary policies and programmes to reduce preventable Marcus Stahlhofer adviser, child and adolescent rights7 consideration. UN, 2013. maternal morbidity and mortality. UN, 2012; Rajat Khosla human rights adviser5 8 Every Woman Every Child Technical Content Workstream para 26 and 38. Working Group on Early Child Development. Effective 19 Office of the United Nations High Commissioner for 1 Human Rights and Economic and Social Issues Section, interventions and strategies for improving early child Human Rights, World Health Organization. Technical Office of the High Commissioner for Human Rights, development. 2015. www.everywomaneverychild.org/ guidance on the application of a human rights-based United Nations, Geneva, Switzerland images/08__ECD_background_paper_for_Global_ approach to the implementation of policies and 2Women’s Rights and Gender Section, Office of the High Strategy_FINAL_2015-03-23.pdf. programmes to reduce preventable maternal morbidity Commissioner for Human Rights, United Nations 9 United Nations Committee on the Rights of the Child. and mortality. UN, 2012; para 48. General comment No 7: implementing child rights in 20 United Nations Committee on the Rights of the Child. 3United Nations Population Fund, New York, USA early childhood. UN, 2005; para 10. General comment No 7: implementing child rights in 4Partnership for Maternal Newborn and Child Health, 10 World Health Organization. Adolescent pregnancy. early childhood. UN, 2005; para 11. World Health Organization, Geneva, Switzerland www.who.int/maternal_child_adolescent/topics/ 21 United Nations Committee on the Rights of the maternal/adolescent_pregnancy/en/. Child. General comment No 7: implementing child 5Department of Reproductive Health and Research, 11 Office of the United Nations High Commissioner for rights in early childhood. UN, 2005; para 21(a), 26, World Health Organization Human Rights, World Health Organization. Technical and 27(b). 6United Nations Children’s Fund, New York, USA guidance on the application of a human rights-based 22 Every Woman, Every Child, Technical Content Workstream approach to the implementation of policies and Working Group on Determinants. Socioeconomic, 7 Department of Maternal, Newborn, Child and programmes to reduce preventable maternal morbidity political and environmental determinants: draft working Adolescent Health Cluster for Family, Women’s and and mortality. UN, 2012; para 30. paper. 2015. www.everywomaneverychild.org/ Children’s Health, World Health Organization 12 Office of the United Nations High Commissioner for Human images/10__EWEC_2_0_Determinants_draft_working_ On behalf of the Human Rights Subwork Stream of the Rights, World Health Organization. Technical guidance on paper_version_24_March_2015.pdf. Global Strategy for Women’s, Children’s and the application of a human rights based approach to the 23 Office of the United Nations High Commissioner implementation of policies and programmes to reduce and for Human Rights, World Health Organization. Adolescents’ Health. eliminate preventable mortality and morbidity of children Technical guidance on the application of a human Correspondence to: J Sanghera [email protected] under 5 years of age. UN, 2014; para 35. rights-based approach to the implementation of Additional material is published online only. To view 13 Office of the United Nations High Commissioner for policies and programmes to reduce preventable please visit the journal online (http://dx.doi. Human Rights, World Health Organization. Technical maternal morbidity and mortality. UN, 2012; para 74 guidance on the application of a human rights based and 75. org/10.1136/bmj.h4184) approach to the implementation of policies and 24 Commission on Information and Accountability 1 Committee on Economic, Social and Cultural Rights programmes to reduce and eliminate preventable for Women’s and Children’s Health. Keeping (CESCR). General comment No 14: the right to the mortality and morbidity of children under 5 years of promises, measuring results: recommendation 7. highest attainable standard of health. UN, 2000; age. UN, 2014; para 28 and 29. WHO, 2011. para 12. 14 International Covenant on Economic, Social and 25 Office of the United Nations High Commissioner for 2 Office of the United Nations High Commissioner for Cultural Rights: article 2(1) (www.ohchr.org/EN/ Human Rights, World Health Organization. Technical Human Rights, World Health Organization. Technical ProfessionalInterest/Pages/CESCR.aspx). guidance on the application of a human rights based guidance on the application of a human rights-based 15 Office of the United Nations High Commissioner for approach to the implementation of policies and approach to the implementation of policies and Human Rights, World Health Organization. Technical programmes to reduce and eliminate preventable programmes to reduce preventable maternal morbidity guidance on the application of a human mortality and morbidity of children under 5 years of age. and mortality. UN, 2012; para 3 and 13. rights-based approach to the implementation of UN, 2014; para 64-67. 3 Convention on the Rights of the Child: article 6 (www. policies and programmes to reduce preventable ohchr.org/en/professionalinterest/pages/crc.aspx). maternal morbidity and mortality. UN, 2012; para 21. Cite this as: BMJ 2015;351:h4184

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National leadership: driving forward the updated Global Strategy for Women’s, Children’s and Adolescents’ Health Implementing the updated global strategy means effective leadership, nationally and sub-nationally—requiring country led health plans, partnerships, accountability, advocacy, and collective action at all levels, say C K Mishra and colleagues

argets, as one would expect, are global investment framework for women’s decision making and enable accountabil- easier to set than to achieve. At the and children’s health.2 ity have contributed to the optimal use of end of this year the millennium We used two approaches to identify the resources in these countries. development goals for reducing guiding principles and enablers for national • Multisector progress: about half of the maternal and child mortality will leadership in driving health outcomes. reduction in maternal and child mortality remainT unmet.1 While most maternal and Firstly, we reviewed the literature to assess in LMICs since 1990 can be attributed to child deaths can be prevented using proved factors that impede the effective delivery of investments in sectors that influence cost effective interventions,2 a range of health interventions in LMICs and their solu- health, such as education, gender parity, ­factors—from poor governance to the lack of tions. Secondly, we held consultations with a water, sanitation and hygiene, and allevi- a skilled health workforce—affect its delivery range of stakeholders including senior polit- ating poverty. While improving its health at scale. This is especially true for the poor- ical and administrative leaders on 25 and 26 outcomes Egypt met its millennium devel- est people in low to middle income countries February 2015 in New Delhi, India, to gain opment goal target to increase sustainable (LMICs), where the burden is highest. their perspective on why leadership matters, access to safe drinking water and basic Not surprisingly, numerous calls have what makes it effective, and how it can be sanitation, and Cambodia reduced pov- been made for effective leadership to priori- sustained. erty across its population by 60% from tise women’s, children’s, and adolescents’ A key outcome of the New Delhi consulta- 2004 to 2011. health needs and to accelerate progress. tions was an agreement on the conceptual Good governance (including corruption con- While this requires the presence of a commit- framework.6 Every Woman Every Child also trol), a focus on value for money, and wom- ted leader, this alone is not enough. Institu- published a more detailed version of this en’s political and socioeconomic tions within and outside government are paper for additional comments. participation were further identified as key equally important: they help to sustain lead- enablers in improving women’s and chil- ership, enable resilience to shocks, and Lessons learnt dren’s health.7 In Ethiopia, where mortality ­further the achievement of development Recent analysis of success factors in 10 fast in under 5s declined by two thirds from 1990 goals.3 4 This is the focus of our paper. Draw- track countries showed that some LMICs to 2012, government reforms to reduce cor- ing on lessons learnt from LMICs, we high- have been able to accelerate progress despite ruption and improve the efficiency of civil light how national leadership can put the low health budgets and considerable social services have made a difference.8 updated global strategy into practice. and political challenges. These were Bangla- desh, Cambodia, China, Egypt, Ethiopia, Framework for applying the global strategy Methods Laos, Nepal, Peru, Rwanda, and Vietnam— The causes of poor health outcomes for The analysis presented here is underpinned which, when the success factor studies women, children, and adolescents relate by a conceptual framework (fig 1 ), which started in 2012, were on track to achieve mil- partly to wider constraints that affect health builds on the World Health Organization’s lennium development goals 4 and 5a. systems and, ultimately, access to services. health systems building blocks5 and the Although no standard formula exists these These include bureaucracies’ failure to incen- countries are moving ahead in three main tivise performance3 and a weak political and Key messages areas to improve women’s and children’s legislative framework that contributes to cor- health7: ruption9 and hinders accountability. Wider institutional deficiencies can affect National leadership—political and admin- the delivery of services for women, • Guiding principles: political vision and istrative—can potentially tackle these wider children, and adolescents emphasis on human rights, alignment of constraints and pave the way for reform. It National leadership can set priorities and development aid with country plans, and can set priorities, revisit the relative roles of pave the way for reform—but, to achieve sustainability have helped these countries stakeholders, and mobilise and harmonise the updated global strategy, it must be to mobilise resources and shape their efforts at the local government, health facil- sustained and effective health systems. For instance, Nepal’s poli- ity, and community levels. Stakeholders To scale up essential health interventions cies on safe motherhood and neonatal include the government, multilateral and and create resilient health systems, health and gender are anchored in the bilateral funding partners, private sector, political commitment must be supported principles of human rights. civil society and non-profit organisations, by investment in country led health • Systematic adoption of evidence based or academic institutions, and the media. planning, management capacity, catalytic strategies: mobilisation of part- To this end, we include a framework illus- partnerships, accountability, advocacy, nerships, effective planning, and the use trating how the updated global strategy can and collective action at all levels of robust and timely evidence to inform be translated into practice (fig 1 ). It highlights

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Advocacy and collective action Management capacity Partnerships

National leadership

Participation of individuals and communities in Supportive legislation and policies Political vision and planning guided by principles design, delivery, utilisation, and monitoring services of human rights, gender parity and equity, value for money, aid e ectiveness, and sustainability Good governance

Country led national health plan

Health system strengthening Delivery of high impact essential Testing and scaling innovations Multisector approach/options Health workforce package of health services Enabling environment through for health influencing sectors Product and technology Task shiing (if appropriate) collaborative partnership, and Education Health information Integrated service delivery flexible nancing Nutrition Performance management New research and development Water, sanitation, health, and Documentation of results, environment measurement, and evaluation Gender Infrastructure

Accountability at all levels

Core elements Key enablers Demand and supply side considerations Implementation: health sector Implementation: health influencing sectors

Conceptual framework to operationalise the Global Strategy for Women’s, Children’s and Adolescents’ Health

how national leadership can implement illus- to be successful only with the political will to.” It can also provide a basis for holding trative policies for future investment—includ- and effective bureaucracy, where the relative leadership accountable. There are, however, ing legislation, programmes, and allocation roles of political and administrative leaders a number of underlying challenges.15 of funds required for implementing the are well defined and adhered to. To this end, Firstly, not all countries are convinced of updated global strategy2—in the context of the following options may be considered: the utility of a national plan (rather than a each country. Of critical importance is the budget) and may view it primarily as a way of need to create an environment where the • Increasing women’s political participation: raising funds—and, where a costed national planning, delivery, and monitoring of services this can affect priorities and resource allo- health plan is in place,15 there is some way to is aligned with the principles of human rights, cation. For instance, a study examining the go before the fundamental principles of aid gender parity, equity, and aid effectiveness implications of political reservations in vil- effectiveness can be met. and is informed by individual and community lage councils across two Indian states found Secondly, there is inadequate capacity to participation. that leaders invested more in infrastructure develop appropriate and flexible plans, as Both of these potentially require policy that dealt with their own gender’s needs.11 well as limited engagement of civil society in changes and measures to improve gover- Similarly, in Rwanda, where 64% of parlia- health policy formulation. Thirdly, disaggre- nance. However, given that today’s leaders mentarians are women, a gender policy gated data including a breakdown of costs have to navigate an increasingly complex informs planning processes.12 are lacking, and there is insufficient empha- landscape—where adversarial political sys- • Selecting and promoting skilled administra- sis on procedures for mutual accountability. tems, trust deficits, and competing interests tive leaders: a key first step to improving Fourthly, requirements of funding agencies, all make the path to reform more challeng- governance is ensuring meritocratic recruit- such as financial and procurement systems, ing—the framework also identifies five key ment through civil service examinations.13 are often not factored in and can lead to inef- enablers for sustaining effective political Stability in government also requires sys- ficiencies and misallocation of funds. and administrative leadership. Together, tems for transparent performance manage- Development of the national plan would these make it more likely for essential health ment and succession planning. require appropriate guidelines based on global interventions to be scaled up in a way that is • Building capacity: a number of tools are good practices, training, and analytical tools operationally, financially, and socially sus- available to increase leaders’ effective- to determine resource allocation; advocacy tainable and also for health systems to ness. These include skill development and and consultation with stakeholders to ensure respond to new challenges and opportuni- peer to peer learning initiatives, as well as buy-in and alignment; a shift towards pooled ties. These enablers, along with options for devolution and decentralisation of power. financing; a framework for measurement and their implementation, are set out below. However, the evidence on their impact has accountability; and a country coordinating been mixed;7 14 as such, identifying strate- mechanism led by the national government. Management capacity gies must involve an analysis of the types A close working relationship between politi- of challenges facing leadership. Partnerships cal and administrative leaders, characterised Partnerships offer leaders a vehicle for align- by a set of shared values and bureaucrats Country led national health plan ing interests and using additional resources, with the autonomy to shape policy, has A country led, costed national health plan, plugging gaps and improving service delivery, helped the progressive development of some including financing and aligned with local developing and distributing low cost public countries—for example, in Botswana, whose priorities and conditions, can help to goods, and fostering greater accountability. top politicians are often former civil ser- improve the targeting of resources and com- Their success, however, depends on whether vants.10 Nevertheless, this approach is likely municate a shared understanding of “how leaders are “credible brokers” who can help to

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change perspectives while empowering Women’s, Children’s and Adolescents’ Health 8 Ministry of Health Ethiopia, PMNCH, WHO, World Bank, AHPSR, and participants in the Ethiopia multi- weaker sections of society.16 Other factors developed, guided, and contributed to this paper. SB, TB, SK, AJJ, and AM were the core drafting team. SB and stakeholder policy review. Success factors for women’s include clear goals, standards, and processes TB also ensured that relevant feedback from the and children’s health: Ethiopia. 2015. www.who.int/ governing transactions between stakehold- consultations for the UN secretary general’s Global pmnch/knowledge/publications/ethiopia_country_ report.pdf. ers,17 as well as investment in technical Strategy for Women’s, Children’s and Adolescents’ Health and from the online consultation were 9 Pinzón-Flórez CE, Fernández-Niño JA, Ruiz-Rodríguez 18 M, Idrovo ÁJ, Arredondo López AA. Determinants of knowledge and performance management. incorporated into the draft. All have read and agreed to performance of health systems concerning maternal the final version. CKM is guarantor. and child health: a global approach. PLoS One Accountability mechanisms Conflicts of interest: We have read and understood 2015;10:e0120747. Perhaps one of the most important ways to BMJ’s policy on declaration of interests and have no 10 Dasandi N; Developmental Leadership Program. The relevant interests to declare. politics-bureaucracy interface: impact on development ensure effective leadership is through appro- reform. 2014. http://publications.dlprog.org/ The authors alone are responsible for the views Pol-Bur_SOTA.pdf. priate monitoring and course correction at expressed in this article, which does not necessarily 11 Chattopadhyay R, Duflo E. Women as policy makers: each level. While most countries will have a represent the views, decisions, or policies of WHO or the evidence from a randomized policy experiment in framework for enabling accountability, this institutions with which the authors are affiliated. India. Econometrica 2004;72:1409-43. http:// economics.mit.edu/files/792. can be strengthened19 by clearly defining Provenance and peer review: Not commissioned; externally peer reviewed. 12 Ministry of Health Rwanda, PMNCH, WHO, World financial and administrative authority; mak- Bank, AHPSR, and participants in the Rwanda C K Mishra, additional secretary and mission director, ing disaggregated data and information on multi-stakeholder policy review. Success factors for National Health Mission, Ministry of Health and Family women’s and children’s health: Rwanda. 2015. www. initiatives publicly available; strengthening Welfare, India who.int/pmnch/knowledge/publications/rwanda_ judiciary and autonomous regulatory mech- Joe Thomas,  executive director, Partners in Population country_report.pdf. and Development 13 Rauch JE, Evans PB. Bureaucratic structure and anisms to provide oversight; ensuring whis- bureaucratic performance in less developed countries. joint secretary, Reproductive, Maternal, tleblower policy and protection; and Rakesh Kumar,  J Public Econ 2000;75:49-71. Newborn, Child and Adolescent Health (RMNCH+A), 14 Lyne de Ver H, Kennedy F; Developmental Leadership engaging better with stakeholders to inde- Ministry of Health and Family Welfare, India Program. An analysis of leadership development pendently monitor implementation. Trupthi Basavaraj, senior consultant, MSG Strategic programmes working in the context of development. 2014. Consulting, UK http://publications.dlprog.org/An%20Analysis%20of%20 Leadership%20Development%20Programmes.pdf. Advocacy and collective action A J James, honorary visiting professor, Institute of 15 International Health Partnership (IHP+). Progress in the Stakeholders outside the government can Development Studies, Jaipur, India International Health Partnership and related initiatives make sure that they fulfil their obligations.4 20 Anshu Mohan, programme manager, Adolescent Health (IHP+). 2014. www.internationalhealthpartnership.net/ and International Partnerships, Ministry of Health and fileadmin/uploads/ihp/Result_2014/Documents/ For instance, once the Turkish government Family Welfare, India IHP_report-ENG-WEB_v2.PDF. had ratified the United Nations Convention on 16 Ansell C. Collaborative governance. In: Levi-Faur D, ed. Shyama Kuruvilla, senior strategic adviser, Family, The Oxford Handbook of Governance. Oxford University the Elimination of all Forms of Discrimination Women’s and Children’s Health, World Health Press, 2012. Against Women, the women’s rights move- Organization, Switzerland 17 Bouman S, Friperson R, Gielen M, Wilms P. Public-private partnerships in developing countries. ment successfully campaigned for a new civil S Basavaraj, managing director, MSG Strategic Consulting, India IOB Evaluations (Netherlands) 2013. www.oecd.org/ and penal code.21 Key principles for effective dac/evaluation/IOBstudy378publicprivatepartnership Correspondence to: C K Mishra [email protected] advocacy22 23 include prioritisation and align- sindevelopingcountries.pdf. 1 Every Woman Every Child. Saving lives, protecting 18 Hellowell M. The role of public-private partnerships in ment of action; identification of evidence futures: progress report on the Global Strategy for health systems is getting stronger. Commonwealth based strategies and “government champi- Women’s and Children’s Health 2010-2015. 2015. Health Partnerships 2012. www.sps.ed.ac.uk/__data/ ­http://everywomaneverychild.org/images/ assets/pdf_file/0008/96245/2012_PPP_getting_ ons”; engagement at every level, including March_17_EWEC_GSR_Layout_v08_LR.pdf. stronger_Commonwealth_Health_Partnerships_2012. individuals, communities, and religious lead- 2 Stenberg K, Axelson H, Sheehan P, et al. Advancing pdf. social and economic development by investing in 19 Partnership for Maternal, Newborn and Child Health ers; and monitoring outcomes and impact. women’s and children’s health: a new global (PMNCH). National accountability mechanisms for investment framework. Lancet 2014;383:1333-54. women’s and children’s health. 2012. www.who.int/ Conclusion 3 Mills A, Rasheed F, Tollman S. Strengthening health pmnch/topics/part_publications/national_ systems. In: Jamison DT, Breman JG, Measham AR, et al, accountability_mechanisms.pdf. Achieving the updated global strategy eds. Disease control priorities in developing countries, 20 Shiffman J. Generating political priority for maternal requires strong political commitment and 2nd ed. World Bank, 2006. www.ncbi.nlm.nih.gov/ mortality reduction in 5 developing countries. books/NBK11747/. Am J Public Health 2007; 97: 796-803. collaborative governance. Although no uni- 4 Keefer P. Collective action, political parties, and 21 UN Women. Progress of the world’s women: in pursuit versal blueprint exists, in countries with pro-development public policy. Asian Dev Rev of justice. 2011. www.unwomen.org/en/digital-library/ high maternal and child mortality rates 2011;28:94-118. publications/2011/7/progress-of-the-world-s- 5 World Health Organization. The WHO Health Systems women-in-pursuit-of-justice. efforts must be directed towards increasing Framework. 2012. www.wpro.who.int/health_services/ 22 Tembo F; Overseas Development Institute. Citizen voice the capacity, skill, and accountability of health_systems_framework/en/. and state accountability: towards theories of change 6 Every Woman Every Child. Stakeholders consultation that embrace contextual dynamics. 2012. www.odi. leaders. Ultimately, the health and wellbeing meeting on the updated Global Strategy for Women’s, org/sites/odi.org.uk/files/odi-assets/publications- of women, children, and adolescents relies Children’s and Adolescents’ Health. 2015. www. opinion-files/7557.pdf. on how countries sustain effective political everywomaneverychild.org/images/SUMMARY_ 23 World Health Organization; Partnership for Maternal, Every_Woman_Every_Child_Stakeholder_ Newborn and Child Health (PMNCH). The PMNCH 2013 and administrative leadership. Consultation_Meeting_3.pdf. report. 2013. www.who.int/pmnch/knowledge/ 7 Kuruvilla S, Schweitzer J, Bishai D, et al. Success factors publications/pmnch_report13.pdf. Contributors and sources: The National Leadership for reducing maternal and child mortality. Bull World working group for the updated Global Strategy for Health Organ 2014;92:533-44B. Cite this as: BMJ 2015;351:h4282

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Innovating for women’s, children’s, and adolescents’ health Innovation is central to reaching the sustainable development goals on women’s, children’s, and adolescents’ health. The task now is to scale up these innovations in a sustainable way, say Haitham El-Noush and colleagues

he progress report on the UN secre- launched an associated Innovation Working A major gap is the lack of a smooth path- tary general’s Global Strategy for Group to advocate for, identify, and support way along which innovations can be scaled Women’s and Children’s Health, innovations to accelerate progress on the up sustainably. Every Woman Every Child is Saving Lives, Protecting Futures, health targets in the millennium develop- uniquely positioned to bridge any gaps by notes that “innovation is essential ment goals. Meanwhile, global partners of providing a platform to deliver strong politi- toT achieving the ultimate goal of ending the secretary general’s strategy were devel- cal and leadership commitments, mobilise preventable deaths among women and chil- oping a pipeline of innovations in women’s, resources, and connect the stakeholders dren and ensuring they thrive.”1 The report children’s, and adolescents’ health. needed to successfully scale up an innova- advocates for integrated innovation, which Research conducted for Saving Lives, Protect- tion. These stakeholders include innovators, combines science and technology and ing Futures showed that more than 1000 universities, small and medium enterprises, social, business, and financial innovation innovations totalling over $255m (£165m; incubators and accelerators, foundations, to enable sustainability and the scaling up €235m) had been supported in the research development agencies, civil society organi- of interventions.2 and development pipeline. sations, multinational corporations, invest- Innovation is required in all aspects of the We are in a watershed year. The transition ment banks, high net worth individuals, and Every Woman Every Child initiative (www. from the millennium development goals to governments. everywomaneverychild.org), including the sustainable development goals provides health systems, social determinants of a pragmatic opportunity to advance the EWEC innovation marketplace health, human rights, leadership, finance, innovation agenda to ensure that the best The Innovation Working Group aims to and accountability, to help to achieve the innovations are scaled up and have maxi- smooth the innovation pathway in a sustain- United Nations’ sustainable development mum impact on saving and improving the able manner by establishing the Every goals. lives of women and children by 2030. Woman Every Child innovation marketplace Strategically, innovation forges non-tradi- In this paper we propose challenges and to facilitate the four interlinked elements of tional partnerships among the public and solutions for the post-2015 period, aimed at innovation: the pipeline, curation, broker- private sectors, attracts new sources of fund- meeting the goals of the Global Strategy for ing, and investment. The group seeks to cre- ing through investment opportunities for the Women’s, Children’s and Adolescents’ Health ate links to already existing resources and private sector and governments, and stimu- and the sustainable development goals. initiatives, thus establishing a more coherent lates creative ways for countries to use inno- system for scaling up innovations in a sus- vation to accelerate attainment of their Methods tainable manner. But it does not propose to health goals. Innovation complements pro- Evidence for this article was gathered from replicate what is already being done well by grammes that achieve results in the near the published literature, UN reports, and others in the innovation ecosystem. Every term but that may not be sustainable without the authors’ experiences in development Woman Every Child provides investors with a ongoing support from donors. innovation. While we cannot claim consen- trustworthy source of investment opportuni- Alongside Every Woman Every Child in sus, this paper was reviewed by members ties that is free from conflicts of interest, 2010 the UN secretary general, Ban Ki-moon, of the Every Woman Every Child Innova- developed by a trusted partner that used tion Working Group and other global transparent criteria and governance pro- Key messages health experts, whose feedback was used cesses. It catalyses the convergence of initia- to modify it. tives and stakeholders in a way that might Innovation in healthcare is essential to the not otherwise be possible. achievement of the post-2015 sustainable What is the problem? development goals Despite important progress, unfortunately Priority interventions Over the past five years over 1000 each year 6.3 million children still die before The goal of the EWEC innovation market- innovations in women’s, children’s, and the age of 5 and 289 000 women die in preg- place is to scale up 20 investments in wom- adolescents’ health have been supported nancy and childbirth. A third of children, en’s, children’s, and adolescents’ health by but few have been fully scaled up in a meanwhile, fail to reach their full potential. 2020 and to enable at least 10 of these inno- sustainable manner Innovation is needed to rectify this situation vations to be widely available and having a To tackle the scaling challenge in and help us reach the new sustainable devel- significant effect by 2030. innovation, the Every Woman Every Child opment goals. In the past five years over One inspiring example of innovation is Innovation Working Group builds networks 1000 innovations in women’s, children’s, the African meningitis vaccine project, of investors and links innovations to and adolescents’ health have been sup- which took 15 years to start saving lives but private sector commitments and national ported. Most of these, however, are at proof has now been used to immunise more than resources, through the brokering function of concept stage, with only a few being fully 215 million people. By 2020 the vaccine is of its innovation marketplace scaled up. expected to protect more than 400 million

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funding at proof of concept stage often deter- Box 1: Examples of innovations* mines which investments are scaled up. Preventing bleeding after childbirth Curation activity must focus on conditions Effort has been made to accelerate the development of an innovative, heat stable, and low cost inhaled with the greatest disease burden and on form of oxytocin to manage postpartum haemorrhage after childbirth in developing countries. An innovations with the greatest potential to innovation was developed by Monash University and initially supported by the Saving Lives at Birth save and improve lives. partners. It is now being accelerated through a collaboration with GlaxoSmithKline, McCall MacBain, the Planet Wheeler Foundation, and Grand Challenges Canada. It has the potential to save the lives of A process and criteria are needed to almost 20 000 pregnant women each year. enable comparison among innovations, especially those vying for further invest- Assisting difficult births ment in certain sub-topics. A good example The BD Odón Device is a delivery assistance device supported by the Saving Lives at Birth partners, of an attempt to do this is the PATH Innova- which is designed to be safer and easier to use in resource limited settings than forceps, vacuum tion Countdown 2030 report, funded by the extractors, or caesarean sections. It has the potential to prevent 200 000 deaths a year in sub- Saharan Africa. Development of this new device continues, in partnership with the World Health Norwegian Agency for Development Coop- Organization (WHO). The medical technology company BD (Becton Dickinson) intends to manufacture eration (Norad), US Agency for Interna- and distribute it at full scale, assuming that ongoing clinical testing validates its safety and efficacy. tional Development (USAID), and the Bill and Melinda Gates Foundation (see http:// Preventing infection among newborns ic2030.org). Many groups, from foundations With investment from the Saving Lives at Birth partners, John Snow International has pioneered the to companies to venture capital firms, do use of the antiseptic compound chlorhexidine in Nepal as a safer, more effective alternative than existing methods for disinfecting a newborn’s umbilical cord stump. Research indicates that routine their own curation when deciding on use of chlorhexidine could reduce the incidence of newborn death by 24%. Already 1.2 million babies investments, but there is no system to share have had chlorhexidine applied to their umbilical cord stump, leading to an estimated more than and build on these efforts. 7500 lives saved in Nepal alone. Scaling up is already occurring in Nigeria and Madagascar, and in Curation may show that some innovations other countries. are not quite ready for investment because *Descriptions adapted from ­www.everywomaneverychild.org/global-strategy-2/gs2-progress-report. they have not reached the stage of scientific proof of concept or because their business people and prevent one million cases of the use of common data elements, allowing plan is poorly developed. This highlights the meningitis A, 150 000 deaths, and 250 000 project information and updates to be easily need for bridge financing in the range of cases of severe disability.3 transferred from one repository to another. $250 to $1m and also for mentoring through The time frame for innovation means that investment readiness programmes such as their full impact may not be felt for five, 10, Curation Lemelson/Venture Well, Duke SEAD, Villgro, or even 15 years.4 Examples of innovations Curation is the comparative analysis of inno- GSBI, and NESsT. that are in the process of being scaled up are vations in the pipeline. It answers the ques- A neutral body associated with the UN in box 1. tion of which of the innovations are best. It is can gain the confidence of investors and a critical step in distilling dozens of innova- governments. The Innovation Working Four interlinked aspects of innovation tions that might be in the pipeline for a wom- Group can stimulate, organise, and finance Pipeline en’s, children’s, and adolescents’ health curation exercises in the sub-topics shown The pipeline comprises early stage innova- sub-topic such as pneumonia down to a few in the ­figure so that the most promising tions supported by investments of $100 000 to of the best to present to an investor who may innovations can be scaled up through brok- $250 000 to reach the proof of concept stage. be interested in supporting an innovation for ering and investment, ultimately achieving There are more than 1000 innovations in the pneumonia. Naturally, what is “best” impact. WHO has a track record of providing pipeline for women’s, children’s, and adoles- depends on the intended audience, and the technical assistance to governments and cents’ health. Examples of key sources of inno- curation process needs to take this into can lend expertise. The working group’s vations in the pipeline are shown in box 2. account. The figure shows a taxonomy of neutrality is crucial, because investors seek Although the innovation pipeline is sub-topics developed through consultation a trustworthy list of investment opportuni- robust, it is difficult to access and analyse. by the Innovation Working Group . ties that is free of conflicts of interest and For example, 1689 innovative projects Currently there is not enough comparison has transparent criteria and governance (including but not limited to women’s, chil- of innovations. The provenance of initial processes. dren’s, and adolescents’ health) in 80 coun- tries are listed on grandchallenges.org. This Box 2: Innovations in pipeline (with key sources) level of information is an advance, but it is difficult to search for all the projects on a • Saving Lives at Birth (USAID, Gates Foundation, Grand Challenges Canada, Norway, UK Aid, Korean International Cooperation Agency) specific topic, access project level informa- • Saving Brains (Grand Challenges Canada and partners including Aga Khan Foundation Canada, tion (potentially including results), analyse World Vision Canada and the Norlien, Bernard van Leer, Maria Cecilia Souto Vidigal, and UBS individual projects, or allow other qualified Optimus Foundations) funders to deposit projects. The Bill and • All Children Thriving, and Putting Women and Girls at Center of Development (Gates Foundation and Melinda Gates Foundation, USAID, Grand partners including Brazil and India) Challenges Canada, and the Results for • Global Innovation Fund, DIV@USAID, Gates Grand Challenges Explorations, Grand Challenges Canada Development Institute are working together Stars in Global Health, and similar innovations to improve the interoperability of these data. • Grand Challenges projects in India, Brazil China, Israel, and Peru and nascent initiatives in Thailand The Innovation Working Group’s role is to and ASEAN countries stimulate funders to refresh the pipeline, to • Every Woman Every Child Innovation Working Group’s Catalytic mhealth Grants Program, supported by monitor it, and to encourage the consolida- Norad through UN Foundation tion of pipeline information to make it easier In addition, there are individual company pipelines, from small and medium enterprises to multinational to access and analyse. A specific example is corporations, and universities are a key source of innovation

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Reproductive Maternal Newborn Child Adolescent Reproductive technologies Antenatal care Civil registration and Malaria Early forced marriage vital statistics (CRVs) Reproductive rights Perinatal care Pneumonia Female genital mutilation (FGM) Prematurity Emergency obstetric care Diarrhoea Empowerment Complications during delivery Postpartum haemorrhage WASH Violence against Newborn resuscitation women and girls Obstruction Nutrition Sepsis Menstrual hygiene Pre-eclampsia Vaccines Early initiation of breast Women’s cancers Postnatal depression feeding (and continuation, etc) Early child development (ECD)

Prevention of mother to child HIV transmission

Stillbirth

Cross-cutting topics Social protection/society safety nets Behaviour change and modi cation Accountability and transparency of systems Data management Service delivery and workforce management

Sub-topics among innovations in the pipeline for women’s, children’s, and adolescents’ health

Brokering ­create a culture of innovation in health min- means of financing innovations. Nothing Brokering is the process of investment due istries. As a neutral platform, the innovation drives innovation like market demand. Scal- diligence and of matching innovations to group can take the lead on brokering and the ing up and adoption of innovative service investors. Brokers need a “line of sight to the development of brokering models, including delivery approaches and new technologies entire community,” including looking “back- using the annual UN General Assembly as a by countries is associated with an annual ward” to curation and “forward” to invest- brokering platform and to celebrate success- decline of about 2% per year in the under ment, to effectively link innovators and ful deals. This is one important way for the 5 mortality rate.7 investors. Communication of the curation EWEC innovation marketplace to add value. Imagine a scenario whereby a health min- effort is important to the marketing of the ister can survey the national gaps in care, investment opportunity, conveying mes- Investment match these gaps to innovations in the EWEC sages of the product’s benefits and, critically, Investment is the process of decision making marketplace, and finance the scaling up of that it is “doable,” given a sound investment for public and private funding of innovations these innovations through procurement, by thesis. Lessons can be learnt here from other of more than $1m. We need ways to access using domestic resources or the UN global impact investment organisations, such as new pools of capital, such as private sector financing facility. Ultimately, countries are the Global Health Investment Fund. investors, and to mobilise countries’ domes- the biggest investors in innovation as it is There is no successful systematic evalua- tic resources. Investors include multina- scaled up, and health ministries institution- tion of experience of offering social invest- tional companies, impact investors, venture alise these innovations. Such a system opti- ments to investors. As Judith Rodin of the philanthropists, “angels,” venture capital mises country leadership and the lifesaving Rockefeller Foundation has pointed out, tril- funds, civil society ­organisations, founda- and life improving power of innovation for lions of dollars in private capital are sitting tions, and governments. The innovation women’s and children’s health. on the sidelines.5 Investors require trust- marketplace is not itself an investment fund Civil society organisations are another worthy channels and an effective and neu- but provides channels that increase opportu- source of finance and are well positioned to tral deal sourcing process through which to nities to invest in innovation. Investment can adopt and scale up innovations. The same make investments that have an impact. An also be enhanced by online platforms such as foundations and development agencies that impact investment manager is needed to bro- the Canadian government’s “Convergence” helped create the pipeline at proof of con- ker such opportunities. platform, which will help create partnerships cept stage will also help finance the most The week of the UN General Assembly, for new blended finance investment vehicles. promising innovations, serving to further and the annual Every Woman Every Child Innovation in women’s, children’s, and reduce risk for subsequent private and pub- innovation sector session, are opportunities adolescents’ health, and in particular its lic investors. to celebrate private sector commitments in shared global governance through the Grand Although beyond the scope of the innova- the form of brokered deals. Examples of bro- Challenges initiatives (http://grandchal- tion marketplace, a country’s regulatory kered deals announced at the assembly lenges.org), has great potential as a domestic environment influences the adoption of include the Odon device (2013) and inhaled resource mobilisation strategy to help coun- innovations. International technical agen- oxytocin (2014). tries reach the sustainable development cies such as WHO have a valuable role in Health ministries have an important role goals.6 Countries support their own innova- making recommendations in support of in selecting innovations on the basis of need. tors because this leads to social and eco- health interventions, including innovations. The Innovation Working Group can help by nomic development and jobs. Country plans More generally, mechanisms that focus on creating “a global platform that thinks under the UN global financing facility—a creating enabling environments for national locally.” This platform would provide user recently launched mechanism that pools health systems to absorb innovations, feedback from frontline staff and bring other resources to fund women’s, children’s, and including the lessons learnt from scaling benefits to countries in terms of procurement adolescents’ health programmes in low and innovations in other countries, would be and distribution. The ultimate goal is to middle income countries—will provide a useful.

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Conclusion and Hayden Rodenkirchen for editorial assistance. The 1 Every Woman Every Child. Saving lives, protecting future plans of the Innovation Working Group would not futures: progress report on the global strategy for In 2010, the challenge for Every Woman Every have been possible without the pioneering work of its women’s and children’s health. http:// Child was to create a pipeline of innovations. inaugural chair, Tore Godal of Norway. everywomaneverychild.org/images/EWEC_ Progress_Report_FINAL_3.pdf. In 2015, a pipeline of over 1000 innovations in Contributors and sources: Authors are co-chairs (AOP 2 Grand Challenges Canada. Integrated innovation, women’s, children’s, and adolescents’ health and PAS) and co-managers (HEN and KLS) of the 2010. www.grandchallenges.ca/ Innovation Working Group. has been created, and the challenge now is to integrated-innovation/. Competing interests: We have read and understood 3 PATH. PATH annual report, 2014. www.path.org/ scale them up. A key strategy of the Innova- BMJ’s policy on declaration of interests and have no annual-report/2014/menafrivac. tion Working Group will be to link existing relevant interests to declare. 4 Singer PA. Measuring impact. Grand Challenges Canada, 2015. www.grandchallenges. activities and gaps in care and to create a The authors alone are responsible for the views ca/2015-annual-letter/. global marketplace for the innovations, where expressed in this article, which does not necessarily 5 Rodin J. Innovations in finance for social impact. they meet investors so that they can be scaled represent the views, decisions, or policies of WHO or the SOCAP, 2014. www.rockefellerfoundation.org/blog/ institutions with which the authors are affiliated. remarks-by-dr-judith-rodin-socap-2014. up sustainably and achieve widespread Provenance and peer review: Not commissioned; 6 Singer PA, Buchsbaum S, Ferguson D. The Grand Challenges approach can help achieve the sustainable impact. The innovation model developed for externally peer reviewed. development goals. Grand Challenges Canada, 2014. women’s, children’s, and adolescents’ health Haitham El-Noush senior adviser, Innovation in Health www.grandchallenges.ca/2014/ may also be useful to pave the way from inno- and Development, Norwegian Agency for Development the-grand-challenges-approach-can-help-achieve-the- Cooperation sustainable-development-goals. vation to impact for other sustainable devel- 7 Jamison DT, Sandbu M, Wang J. Why has infant mortality Karlee L Silver vice president, programmes, Grand opment goals in the post-2015 era. decreased at such different rates in different countries? Challenges Canada We thank members of the Innovation Working Group for Disease Control Priorities Project, 2004. Working comments on earlier versions of this paper and in Allan O Pamba vice president, East Africa Cluster and paper No 21. http://citeseerx.ist.psu.edu/viewdoc/ particular for the extensive contributions to the brokering African Government Affairs, GlaxoSmithKline download?doi=10.1.1.200.834&rep=rep1&type=pdf. and investment concepts by Tone Rosingholm of JP Peter A Singer chief executive, Grand Challenges Canada Morgan. We thank colleagues at WHO for their comments Correspondence to: P A Singer on an earlier version of this paper and Elizabeth Munn [email protected] Cite this as: BMJ 2015;351:h4151

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Financing women’s, children’s, and adolescents’ health While global investment in women’s, children’s, and adolescents’ health has increased in recent years, significant gaps remain. Geir Lie and colleagues propose five strategic shifts in financing

Better health is not a cost; it is a benefit, and ­documents, including “grey” (not formally risen by an average of 11% a year.7 (The there is strong evidence that investing in published) literature, datasets, and the lat- Muskoka method8 was used to calculate health and in women, children, and adoles- est estimates from the World Bank, the Part- this figure.) cents yields significant benefits to society nership for Maternal, Newborn & Child Although pledges to women’s and chil- and the economy.1-5 The primary benefits Health, and the World Health Organization dren’s health remain strong on the world can be measured in terms not only of saved (WHO). In addition to the latest evidence, stage, this has not necessarily been the case lives but also longer and healthier lives. The and informed by a synthesis of existing at the country level. Recent (2010 to 2013) secondary benefits are economic and mani- research, a consensus on the manuscript data on health expenditure show that gov- fest themselves in productivity gains and was reached by the Financing Working ernments in 12 countries (Benin, Burkina economic progress. Recent estimates have Group of the Global Strategy for Women’s, Faso, Cambodia, Cote d’Ivoire, Democratic noted that as much as 25% of growth in full Children’s and Adolescents’ Health. A draft Republic of the Congo, Gambia, Niger, Sierra income (which measures the full economic of the paper was circulated for public consul- Leone, Tajikistan, Tanzania, Togo, and benefit of better health as valued by individ- tation and was finalised in line with the com- Uganda) are the smallest funding source for uals) in low and middle income countries ments received. reproductive, maternal, neonatal, and child between 2000 and 2011 resulted from health, at 21% of overall funding in each improvements in health.2 Background to the global strategy country, whereas external resources contrib- However, far too many newborns, chil- Launched in 2010 by the secretary general of ute 30%.9 Although in some cases “aid fungi- dren, adolescents, and women still die from the United Nations, the Global Strategy for bility” (use of aid in ways not intended by preventable conditions every year, and far Women’s and Children’s Health has fuelled the donors when disbursing the funds) may too few have reliable access to good quality efforts to deliver the UN millennium develop- have contributed to this, by crowding out health services. Scaling up from the current ment goals. The Global Strategy and the government and private sector funding, it levels of healthcare coverage to the global Every Woman Every Child advocacy move- still leaves households as the main source of convergence targets (that is, a mortality rate ment have promoted collective action, joint funding for reproductive, maternal, neona- among under 5s of no more than 16 deaths messaging, and effective partnerships. tal, and child health, at 49% of all expendi- per 1000 live births, an annual death rate By 2014 the strategy had gathered more ture in these countries. from AIDS of 8/100 000 population, and an than 400 commitments from more than 300 annual death rate from tuberculosis of partners around the world, ranging from Post-2015 financing framework: 4/100 000 population2) currently faces a sig- governments, civil society organisations, understanding the resources needed nificant financing gap. The World Bank has foundations, and academia to professional As the world transitions from the UN millen- estimated that $33.3bn (£21.4bn; €30.4bn) groups, businesses, and international nium development goals to a post-2015 world would be needed in 2015 alone in the 63 high organisations. The Partnership for Mater- of sustainable development goals, a consid- burden, low and lower middle income coun- nal, Newborn & Child Health has estimated erable part of the agenda for reproductive, tries included in the “Countdown to 2015” that financial pledges to the strategy maternal, newborn, child, and adolescent initiative (www.countdown2015mnch.org), reached almost $60bn in 2011-15, 18% of health remains unfinished, despite the prog- equivalent to $10 per person.6 which (almost $11bn) was contributed by 27 ress made so far. low income countries.7 Of the 20 largest The current need for resourcing highlights Methods pledges, several were represented by global in a dramatic way the urgency of scaling up The paper was based on a literature review partnerships, countries, foundations, financing. Although this scaling up can be and synthesis of evidence from relevant non-governmental organisations, multilat- financed by countries’ expected economic eral organisations, and the private sector.7 growth (given that this growth will far exceed Key messages Disbursement of these pledged funds has the estimated cost of financing health over 2 Evidence is strong that investing in grown steadily, and by May 2014 almost the 2015-2030 period ), challenges lie ahead. women, children, and adolescents yields 60% ($34.2bn) had been disbursed. This fig- Challenges facing the financing landscape significant health and economic benefits ure relates to financial commitments only: in addition to these, many commitments The current gap in financing can be bridged Global investment in women’s, children’s, made to the global strategy are not easily only through dramatic increases from and adolescents’ health has risen in recent years monetised, so potentially more has been domestic and international sources and from committed than the numbers alone are both public and private sectors. However, There is a big gap between current levels showing. over the next few years we expect big shifts of investment and current and future Despite the global economic downturn, in the global economic picture, in the health resource needs for reproductive, maternal, the world has remained resolute in its financing landscape, and more broadly in newborn, child, and adolescent health pledges to the Global Strategy for Women’s the development financing landscape. Strategic shifts in the financing landscape and Children’s health. Official development Economic growth has the potential to pro- could reduce this significant gap in a post- assistance disbursements for reproductive, vide considerable resources, but the transi- 2015 world maternal, neonatal, and child health has tion of countries from low income to middle

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income status is often accompanied by wid- of total pooled health expenditure, reduce ­especially in those countries facing gradua- ening inequities between rich and poor peo- barriers to the reallocation of these funds tion. Countries could strengthen health ple and by insufficient prioritisation of towards priority services and beneficiaries, bonds by securing credit enhancement health. Poor targeting, inadequate use of and implement strategic purchasing and mechanisms (for example, guarantees and evidence, and fragmented financing reduce performance based financing. These steps performance payments to “buy down” inter- the efficiency of existing investments. The require a better dialogue between finance est rates) through multilateral development poor state of civil registration and vital sta- and health ministries to leverage more effi- banks or bilateral agencies (or both). In addi- tistics systems hampers the ability to moni- cient and equitable domestic financing. tion, such instruments could “crowd in” pri- tor progress and base decisions on sound Countries’ ability to use taxation to vate capital, targeting investors such as evidence. The lack of a skilled health work- expand the overall fiscal envelope must be sovereign wealth funds, corporate treasur- force, particularly at the community level in strengthened, and they must promote dia- ies, and private investors, who are increas- many countries, robs health systems of their logue with their finance ministries and sub- ingly looking for investments with joint first line of preventive action and defence national bodies on reducing regressive economic and social returns and who are and also a crucial employment opportunity subsidies and reallocating the resources that willing to accept some risk for greater in poor communities. are freed to programmes that target poor reward. The recently announced partnership An analysis conducted by the Bill and people. They could also explore new ways to between the Global Financing Facility and Melinda Gates Foundation shows that generate domestic health revenues, such as the International Bank for Reconstruction between 2014 and 2030 an estimated 41 through expansion of “sin taxes,” debt and Development, is an excellent opportu- countries are expected to graduate from the swaps, and the floating of bonds marketed to nity to put this into practice, as does emerg- World Bank’s fund for the poorest countries, diaspora communities. ing thinking within the Global Fund to Fight the International Development Associa- AIDS, Tuberculosis and Malaria and in tion.10 Additionally, 15 countries are Integrated approach USAID. expected to graduate from the African Devel- We must break down the separate silos of opment Bank’s Africa Development Fund, 15 financing for women’s, children’s, and ado- Incentivising innovation are expected to graduate from the Asian lescents’ health, including in the areas of We must explicitly focus on financing and Development Bank’s Asian Development nutrition and communicable disease. This incentivising innovation. The pipeline of Fund, and as many as 38 are expected to will require enhanced collaboration between innovation for women’s, children’s, and graduate from the Global Alliance on Vac- the international agencies in strengthening adolescents’ health is the most robust it cines and Immunization.10 Such graduations health systems and moving towards universal has ever been. However, without attention can be welcomed as a sign of prosperity and health coverage so as to reach hard to reach to the financing and regulatory pathways progress but must also be managed carefully populations, while strengthening the funding that enable these innovations to be scaled to ensure that citizens at the greatest risk are base for activities with clear collective bene- up, there will be substantial delays in get- not left behind. fits, such as the eradication of malaria. ting lifesaving innovations to the women, Experience has shown that this increased children, and adolescents who need them “funding for health” will not occur automat- Conflict settings most. We should develop pathways for pri- ically: while in low income countries each We must develop a better mechanism for vate investment and innovative financing percentage point increase in economic financing the health of women and children approaches, so that the quality of health- growth is associated with growth in govern- who live in conflict or post-conflict settings. care, and people’s access to it, can be ment spending on health of more than one Currently, over half of all child and maternal scaled up. percentage point, in lower middle income deaths occur in areas that are in conflict or As much as possible, programmes sup- countries the associated growth is less than just recovering from conflict. Developing ported by donors will integrate a results half a percentage point.11 The effect of this new ways to finance health improvements focused approach (such as results based smaller rise in spending is compounded by among people in these settings, as well as to financing or output based aid) with attention the fact that, as countries reach lower middle increase accountability for the results, needs to building aid flows into countries’ public income status, development assistance for to be prioritised. One approach would be to finance management systems. Programmes health begins to fall, as donors’ graduation create pooled funds that transfer funding to should include support for institution build- policies start to take effect. These combined frontline providers through performance ing—in particular, strong health purchasing effects can create major challenges for coun- contracts. These pools would be governed agencies and related governance and tries, particularly given that they often come through participatory mechanisms and accountability measures. Although the at the same time as the countries are dealing placed under citizens’ control. ­toolbox of innovative financing options with other issues, such as decentralisation, a could not be fuller, few examples of this type greater need to tackle inequity (including Innovative financing models of financing are yet operating on a substan- pockets of vulnerability), and a shift to a We should foster innovative financing mod- tial scale. By actively encouraging invest- growing burden of non-communicable els at the global, regional, and national lev- ment and creating a dialogue about major ­disease. els. Innovative financing mobilised nearly gaps and how innovative financing $100bn for health and development between approaches might help fill them, we stand a Five strategic shifts 2001 and 2013, and such financing has better chance of these investments having a We propose five strategic shifts in the financ- grown by about 11% a year.12 One example of large scale impact. ing landscape for women’s, children’s, and innovation is to shift a portion of the domes- adolescents’ health in the post-2015 world. tic financing into the future by using health Conclusions bonds as a bridge to meet upfront financing The wide financing gap will not be bridged Value for money needs. unless we completely re-imagine the way our Achieving value for money must be made a This would create more fiscal space in various sources of financing for healthcare priority. Countries must increase their share the short term for domestic expenditure, are organised—and will not be bridged

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through harmonisation alone, which is further and bring our collective will and 1 Stenberg K, Axelson H, Sheehan P, et al. Advancing social and economic development by investing in ­necessary but not sufficient. We need more ­creativity to bear, to finance not only a reduc- women’s and children’s health: a new global creativity in examining the inter-relations tion in but an end to preventable child and investment framework. Lancet 2014;383:1333-54. between existing sources of funds. maternal deaths by 2030, along with an end 2 Jamison DT, Summers LH, Alleyne G, et al. Global health 2035: a world converging within a generation. Lancet We call for an unprecedented funding to the epidemics of HIV and AIDS, tuberculo- 2013;382:1898-955. effort over the coming 5-10 years to finance sis, and malaria. 3 Guttmacher Institute. Adding it up: the costs and benefits of investing in sexual and reproductive the next phase of the Global Strategy for Contributors and sources: The Financing Working health 2014. www.guttmacher.org/pubs/ Women’s, Children’s and Adolescents’ Group of the Global Strategy for Women’s, Children’s AddingItUp2014.html. and Adolescents’ Health devised the article. GSSL, Health and to bring to bear, in a collaborative 4 Heckman JJ. Four big benefits of investing in early ALBS, and SB wrote the first draft. The Financing childhood development. http://heckmanequation.org/ fashion, the entire range of financing oppor- Working Group contributed to subsequent drafts. content/resource/4-big-benefits-investing-early- tunities outlined here—domestic and inter- GSSL ensured that relevant feedback from the childhood-development. consultations for the global strategy, online 5 World Health Organization. Health for the world’s national, public, and private—to accomplish consultation, and the peer review process were adolescents: a second chance in the second decade. this task. Agreements to close the overall gap incorporated into the draft. All authors have read and WHO, 2014. www.who.int/maternal_child_adolescent/ would need to be discussed at a country level agreed to the final version. GSSL is the guarantor. The topics/adolescence/second-decade/en. members of the Financing Working Group are Suprotik 6 World Bank. Global financing facility: business plan. and included as part of the post-2015 overall Basu (UN secretary general’s special envoy for May 2015. http://pubdocs.worldbank.org/pubdocs/ monitoring framework. financing the health MDGs and for Malaria, MDG publicdoc/2015/7/598311437686176148/1515268- GFF-Business-Plan.pdf. Health Alliance), Pascal Bijleveld (Unicef), Elina Dale Countries should seek to reap the full ben- 7 World Health Organization. The PMNCH 2014 (WHO), Tore Godal (Norway), Lars Grønseth (Norway, efits and financial capabilities of the multi- accountability report: tracking financial commitments WHO), Nicole Klingen (World Bank), Joseph Douglas to the Global Strategy for Women’s and Children’s lateral development banks, such as the Kutzin (WHO), Rama Lakshminarayanan (World Bank), Health. www.who.int/entity/pmnch/knowledge/ World Bank Group, Inter-American Develop- Geir Sølve Sande Lie (Partnership for Maternal, publications/pmnch_report14.pdf?ua=1. Newborn & Child Health), Ingvar Theo Olsen (Norway), ment Bank, African Development Bank, 8 G8 Information Centre. Methodology for calculating and Agnes L B Soucat (World Bank). baselines and commitments: G8 member spending on Asian Development Bank, and Islamic Competing interests: We have read and understood maternal, newborn and child health. www.g8.utoronto. Development Bank. The emerging New BMJ’s policy on declaration of interests and have no ca/summit/2010muskoka/methodology.html. relevant interests to declare. 9 World Health Organization. Global health expenditure Development Bank may also present an database. www.who.int/health-accounts/ghed/en. opportunity once it is up and running. Grant The authors alone are responsible for the views 10 Salvado R, Walz J. Aid eligibility and income per capita: financing available from bilateral organisa- expressed in this article, which does not necessarily a sudden stop for MICs. DPAF Working Paper Series represent the views, decisions, or policies of WHO or the 2013/05. Bill and Melinda Gates Foundation, tions such as the Global Fund to Fight AIDS, institutions with which the authors are affiliated. Development Policy and Finance Department. 11 Xu K, Saksena P, Holly A. The determinants of health Tuberculosis and Malaria, Gavi (the Vaccine Provenance and peer review: Not commissioned; expenditure: a country-level panel data analysis. 2011. externally peer reviewed. Alliance), UNITAID, and other pooled funds www.who.int/health_financing/documents/ could complement the multilateral develop- Geir Sølve Sande Lie economist, Partnership for cov-report_e_11-deter-he/en. Maternal, Newborn & Child Health 12 Global Development Incubator. Innovative financing for ment bank platforms. development: scalable business models that produce Agnes L B Soucat lead economist, global leader, World The financing mobilised so far in support economic, social, and environmental outcomes. Sep Bank of Every Woman Every Child, and the 2014. www.globaldevincubator.org/wp-content/ Suprotik Basu chief executive officer, Office of the UN uploads/2014/09/Innovative-Financing-for- remarkable reductions in suffering and Secretary General’s Special Envoy for Financing the Development.pdf. death that this has enabled, proves that Health MDGs and for Malaria, MDG Health Alliance ­success is possible. Now, we must reach even Correspondence to: G Lie [email protected] Cite this as: BMJ 2015;351:h4267

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Women’s, children’s, and adolescents’ health in humanitarian and other crises The worst rates of preventable mortality and morbidity among women, adolescents, and children occur in humanitarian and other crises. Sarah Zeid and colleagues discuss the specific attention that is needed for women, adolescents, and children in crises and fragile settings

he millennium development goals organised an expert meeting in Abu Dhabi deaths and 2.6 million stillbirths occurred in highlighted women’s and chil- on 10-11 February 2015, hosted by the govern- low and middle income countries, many of dren’s health and galvanised ment of the United Arab Emirates. This meet- which had been affected by complex human- unprecedented efforts by and ing, chaired by Princess Sarah Zeid, focused itarian emergencies.8 9 More than 250 mil- between governments, civil society, on sexual, reproductive, maternal, newborn, lion children under the age of 5 live in theT private sector, and development organi- and adolescent health in humanitarian and countries affected by armed conflicts.10 sations to meet the needs of the world’s fragile settings, with the purpose of formu- At any given time 4% of disaster affected poorest people. However, as global, national, lating policy recommendations for incorpo- populations are pregnant, about 15% of and local partners work to build on the ration into the revised Global Strategy of the whom will experience an obstetric compli- momentum of the goals with an ambitious United Nations secretary general’s Every cation.11 Risks associated with childbear- post-2015 development agenda, crises and Woman Every Child initiative. A draft of this ing are compounded for girls who are fragile settings have devastating effects on paper was circulated for public comment exposed to forced or transactional sex.12 individuals’ and families’ wellbeing, physi- through a consultation process and finalised Without access to emergency obstetric ser- cal security, and future prospects. Urgent based on the responses received. vices, many women and girls will die attention is needed to ensure that sexual and during pregnancy or childbirth, and many reproductive health interventions—vital for Women, children, and adolescents are more suffer preventable long term health the health and dignity of women, children, adversely affected in humanitarian crises consequences.13 and adolescents—are available and accessi- The worst mortality and morbidity rates for Women and adolescent girls, especially ble to those in emergency settings. women and children occur in chaotic envi- those in fragile or hostile settings, face gen- This paper highlights the critical needs for ronments that are caused by, and create, der based exclusion, marginalisation, and reproductive, maternal, newborn, child, and breakdowns in governance, rule of law, and exploitation, including sex and gender adolescent health in emergency settings support systems. They are characterised by based violence. Gender inequality is a bar- and, based on evidence, offers key recom- destruction of public infrastructure includ- rier to accessing essential services, and con- mendations to effectively tackle these needs. ing health facilities, massive population dis- tributes to harmful practices such as early placement, insecurity, and a collapse of the and forced marriage. These can increase Methods social contract. Hostilities may be actively during emergencies, resulting in early preg- This paper is based on a desk review of evi- directed at stigmatised populations, and nancies that further threaten girls’ lives.14 15 dence and inputs from public consultations governments may become hostile to dis- Older women and women and girls with dis- and expert meetings organised as part of the placed populations. abilities or HIV are at heightened risk and new Global Strategy for Women’s, Chil- More than 80% of the 25 and 44 countries require special measures.16 17 dren’s and Adolescents’ Health. UNFPA classified as making either “no progress” or In countries emerging from conflict con- “insufficient progress” towards millennium tinued lack of access to healthcare, psycho- Key messages development goals 5 (to improve maternal logical and social support, and justice, health) and 4 (to reduce child mortality coupled with ongoing sex and gender based Meeting the health needs of women, rates), respectively, have suffered a recent violence, impede recovery and development. children, and adolescents in crises and conflict, recurring natural disasters, or both. Often countries’ longer term development fragile settings is the most fundamental Worldwide, women and children are up to 14 planning processes fail to include prepared- step on the pathway to both sustain the times more likely than men to die in a disas- ness, response, and recovery. Globally, many gains of the millennium development 1 goals and achieve the sustainable ter. Over 75% of 84 million people in need of sustainable development goal targets will development goals humanitarian assistance in 2014 were not be reached without tailored attention to women and children, the majority of whom sustainable, inclusive development for Strategic action to tackle and prioritise were impoverished.2 3 Poor people suffer women and children in humanitarian and support for reproductive, maternal, most from natural disasters—95% of disaster other crises.10 newborn, child, and adolescent health is fundamental to human dignity fatalities occur in low and middle income countries.4 Broadening the scope of Global Strategy Such action must be more context In the 50 most fragile states (based on Rising numbers of young people combined sensitive, adapted to and for changing OECD data),5 60% of preventable maternal with declining fertility and the right invest- circumstances and across the life course deaths6 and 53% of preventable under 5 ments can lead to a “demographic dividend,” The health interventions and overall deaths7 take place in settings of conflict, dis- which is a boost in economic productivity response to crises in humanitarian and placement, and natural disasters. Neonatal owing to more people in the workforce with fragile settings must be better anticipated, mortality is highest in these circumstances. fewer dependants.18 In this context the planned, and resourced In 2012 99% of the 2.9 million newborns importance of women’s, children’s, and ado-

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lescents’ health needs in crises and fragile Efforts must be driven by demand, owned Firstly, health sector interventions should settings is the most fundamental step on the by and accountable to local communities, be more agile. Planning resilience with pathway to both sustain the gains of the mil- and aimed at reinforcing social networks at communities is important so that their lennium development goals and achieve the the household and community levels that capability and capacity to respond to sustainable development goals. enhance quality of life. Young people and humanitarian shocks is enhanced, and the The next Every Woman Every Child Global women must be empowered as they are the severity and duration of any deviation from Strategy must be people centred and guided true “first responders” to a crisis.20 Boys and the path to sustainable development is by both human rights norms and humani- men should also be engaged to support bet- reduced.21 To this end, health sector plan- tarian principles. It must fully integrate ter sexual and reproductive health out- ning and intervention should be shaped by humanitarian and sustainable development comes—their positive contributions to these population data, respond to health sector action through a “contiguum approach,” are largely unexplored. We propose five rec- risk assessments and local hazards, and be which means tackling relief, recovery, and ommendations for achieving more sustain- tailored to specific needs. To address ineq- development simultaneously rather than able development for women, children, and uities, health services (including commodi- consecutively.19 adolescents in crises. ties, supplies, and human resources) and

Box 1 Recommended interventions for newborns and children Key health matters to be tackled • Newborns: preterm, low birth weight, sepsis, intrapartum complications • Children: malaria, pneumonia, diarrhoea, measles, malnutrition, and mental health and wellbeing Health interventions Newborns • Preventive care: Thermal care, protection and promotion of immediate and exclusive breast feeding, prevention and care of low birth weight, chlorhexidine for umbilical cord care, vaccination, dexamethasone, toxycolics, hygiene, prevention of mother to child transmission of HIV • Treatment: kangaroo care, antibiotics, newborn resuscitation and intensive care, intrapartum care, emergency obstetrics care, oxygen, antiretroviral treatment Children • Preventive care: Longlasting insecticide treated bed nets and indoor residual spraying of insecticides, measles vaccination, infant and young child feeding interventions, adequate complementary feeding, psychosocial health • Treatment: Antibiotics, artemisinin based combination therapy, oral rehydration salts, zinc, vitamin A, ready to use therapeutic foods, mental health support • Delivery models: transit site clinics, community based care such as integrated community case management and community based management of acute malnutrition, home based care. • Campaigns: mass measles vaccinations, distribution of insecticide treated bed nets, child health days, mass malaria care, chemotherapy Non-health interventions • Water, sanitation, and hygiene • Nutritional status screening of infant and growth monitoring • Communication and education on child and maternal nutrition in emergencies • Micronutrients distribution for children 6-59 months • Early childhood development • Child friendly spaces • Basic education • Child protection • Psychosocial support • Birth certificates and registration • Early stimulation • Cause of death surveillance Health system enablers Resilience • Age and sex disaggregated data to assess populations in need and reached • Integrate risk assessment and analysis into resilient systems and services • Develop capacity of health systems to have flexible and adaptable financing and service delivery, trained and available staff, priority drugs available when needed, reliable information systems, and leadership and governance that take into account emergency risk • Newborn cause of death notification and audit • Include children in the design, planning, and implementation of health policies and programmes from preparedness to the onset of an emergency • Re-establishment of or repairs to healthcare infrastructure, support of referral system • Strengthen routinely used laboratories and disease surveillance systems Innovation • Pneumococcal vaccine, rotavirus, Haemophilus influenzae type B vaccine, dispersible tablets, single dose vaccines, single dose antibiotics, vaccines that don’t need to be kept cold, remote monitoring and teaching, m-health • Micronutrient powder • Newborns: Prefilled, single use injection device filled with gentamicin, cycloheximid for cord care, Doppler technology, gestational age estimate methods, aspartate aminotransferase AST for preterm labour at home, simplified antibiotic therapy for sepsis in young infants

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Box 2 Recommended interventions for adolescents Key health matters to be tackled • Early pregnancy, HIV/AIDS and other sexually transmitted infections, unsafe abortion, sexual and gender based violence (including child early forced marriage and female genital mutilation), menstrual hygiene, nutritional deficiencies, traumas Health interventions • Preventive care: Contraception, condoms, emergency contraception, prevention of sexual and gender based violence, mental health, sexuality education, life skills, maternal healthcare including family planning counselling, voluntary counselling and testing for HIV, iron and folic acid supplements • Treatment: Treatment of traumas and orthopaedic surgery, emergency obstetric and neonatal care services, contraception, nutrition, comprehensive abortion care, clinical care for survivors of sexual violence, treatment of sexually transmitted infections, emergency skilled birth attendance, postnatal care including for postpartum depression, antiretroviral treatment • Delivery models: Flexible and integrated adolescent friendly health services, temporary clinics that are community based and mobile, provision of comprehensive sexual and reproductive health services for adolescents at a single site, home based care, education and outreach through non-health facilities, safe spaces, adolescent adaptation of minimum initial services package and assessment • Kits: Menstrual hygiene kits (dignity kits), post-rape kits, sexually transmitted infection kits, contraception kits Non-health interventions • Ensure schooling options through targeted support (safe passage, financial support to families) and vocational training • Access to life skills and comprehensive sexuality education in and out of schools • Protection of girls from child marriage • Systems for adolescent participation in decision making (especially for girls) at community, provincial, and national levels • Strengthen links between programmes and referral pathways and coordination between sectors, including protection, education and livelihoods, for a holistic, multisectoral response • Safe spaces, especially for girls Health system enablers Resilience • Data disaggregated for age, sex, and disability • Qualified and dedicated adolescent sexual and reproductive health staff, including clinical staff (community health workers, nurses, midwives, doctors, paramedics, nationals and international volunteers) • Surveillance of priority illnesses including malnutrition and mortality • Include adolescents in the design, planning, and implementation from the onset of an emergency, as well as in monitoring and evaluating projects • Community and parental involvement Innovation • Use of social media to promote access to quality health information and information sharing • Flexible outreach strategies, including transportation budgets in view of reaching adolescents in insecure environments and otherwise hard to reach areas • Focusing on adolescent and youth specific potential for, and actual contributions to, community resilience, response, and recovery as part of sustainable development

Box 3 Recommended interventions for women Key health matters to be tackled • Pregnancy and childbirth, sexual and gender based violence, family planning, tuberculosis, HIV/AIDS, sexually transmitted infections, situation specific diseases (for example, Ebola virus disease and cholera), mental health (including post-traumatic stress, trauma) and malnutrition Health interventions • In the event of a humanitarian emergency, ensure that the minimum initial services package is implemented and coordinated • Preventive care: Sex education, prevention of sexual and gender based violence, contraception (with a focus on long acting, emergency contraceptives), post- exposure prophylaxis, menstrual hygiene management, HIV prevention, micronutrients, antenatal care • Treatment: Skilled birth attendance, emergency obstetric and neonatal care services, caesarean section, comprehensive abortion care, treatment of sexually transmitted infections, postnatal care including for postpartum depression, treatment of traumas and orthopaedic surgery, clinical management of rape including post-exposure prophylaxis, antiretroviral treatment • Delivery models: minimum initial services package, efficient referral, mobile clinics, community based service delivery • Medical devices and kits: Manual vacuum aspiration, vacuum extraction, Doppler for fetal monitoring, prefilled single use injection device for Depo-Provera Non-health interventions • Water, sanitation, and hygiene: hygiene education, ensure functioning in health facilities for staff and patients, and manage medical care waste • Safe spaces for women • Baby friendly spaces • Psychosocial care including for post-traumatic stress • Conflict sensitive programmes that promote women’s and young people’s engagement in peace building • Reparations and justice mechanisms (for example, for sexual and gender based violence); documenting evidence of human rights abuses • Promote women’s and young people’s participation in decision making and all levels of humanitarian response Health system enablers Resilience • Foster stewardship and ownership of local health authorities • Human resources strategies: task sharing, protection and retention of health workers, increasing numbers of female service providers including community

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based health workers and midwives, capacity building in multi-hazard risk assessment, disaster preparedness, surveillance, infection prevention and control, • Promotion of policies that enable sexual and reproductive health and associated commodities for all phases of the emergency • Service delivery, logistics, and supply chain: re-establishment and repairs of infrastructure, supportive referral system • Suspend user fees where these apply and may be a barrier to access • Open source database with health management information system, disaggregated data for sex, age, and disability of populations affected by the emergency to monitor equity of access • Accountability and quality strategies Innovation • Use social media and mobile technologies for communications, data management, cash transfers, programming, crowd sourcing, and monitoring • Non-pneumatic anti-shock garments for postpartum haemorrhage • Telemedicine and new methods of rapid diagnostics and new vaccines

interventions must be available, accessible, Finally, reliable, flexible financial flows across humanitarian and development acceptable, accountable, and of high qual- are needed outside of state led mechanisms. stakeholders not only to bridge gaps but also ity. Some populations may be outside the This is critical in humanitarian contexts to maximise the opportunities for sustained reach of governments but will be accessible where crises result in the collapse of govern- impact on the health and wellbeing of nonetheless by humanitarian organisa- ment capacity to finance, manage, and women, children, and young people. tions. Of central importance are adequately deliver services. However, funding of risk Contributors and sources: The Every Settings working trained, resourced, and secure healthcare assessment, preparedness, and recovery is group for the Global Strategy for Women’s, Children’s workers, requiring mechanisms to ensure also critical, and requires stronger alignment and Adolescents’ Health devised the article. SZ, KG, DE, security and safety. between development and humanitarian RK, and HD wrote the first draft. The Every Settings working group members HP, NR, AS, and NF contributed Secondly, investment in stronger, more financial flows, which is best achieved by to subsequent drafts. RK and DE ensured relevant resilient healthcare and support systems is sustainable development planning over sev- feedback from the consultations for the UN secretary required for more reliable and secure access eral years by countries. general’s Global Strategy for Women’s, Children’s and Adolescents’ Health, and the online consultation were to essential health services and to life saving incorporated into the draft. All have read and agreed to commodities, such as those necessary to pro- Critical interventions throughout life the final version. KG is guarantor. tect women and adolescent girls from Tailored intervention packages are recom- Conflicts of interest: We have read and understood BMJ unwanted pregnancies to reduce the burden mended for greater effectiveness in human- policy on declaration of interests and have no relevant interests to declare. of sexually transmitted infections and HIV/ itarian and fragile settings. Reliable and Provenance and peer review: Not commissioned; AIDS. The ability to respond during times of timely funding to support these interven- externally peer reviewed. crisis should be built into health systems, to tions is critical, and governments of affected The authors alone are responsible for the views absorb shocks, adapt to changed circum- countries and international donors must expressed in this article, which does not necessarily stances, and return to optimal levels of func- prioritise these interventions. Based on represent the views, decisions, or policies of WHO or the institutions with which the authors are affiliated. tionality as soon as possible. Multisector guidelines set by UN agencies and major Sarah Zeid, adviser1 engagement of national and local stakehold- governmental and civil society organisa- Kate Gilmore, deputy executive director2 ers, such as ministries of health and educa- tions in emergency response, we recom- Rajat Khosla, human rights adviser3 tion and local communities, in disaster risk mend the critical interventions for children Heather Papowitz, senior adviser4 assessment and emergency preparedness and newborns (box 1), adolescents (box 2), Danielle Engel, technical specialist2 must be prioritised. The police and military and adult women (box 3). A full list of the Henia Dakkak, programme adviser2 should understand health is an essential sources used to make these recommenda- Njoki Rahab, senior gender adviser5 part of human security. tions are available in the data supplement senior director6 Thirdly, communications technology, on thebmj.com. Anita Sharma, 2 including social media, should be used more Mollie Fair humanitarian programme specialist 1 effectively. It offers opportunities to better Conclusion Partnership for Maternal, Newborn and Child Health, World Health Organization, Geneva, Switzerland influence health seeking behaviour, to sup- Humanitarian needs are increasing, and we 2United Nations Population Fund, New York, USA port health workers, to help adapt health must ensure that essential healthcare services 3Department of Reproductive Health and Research, systems to local contexts, and to ensure and lifesaving interventions are available in World Health Organization, Geneva 2211, Switzerland greater accountability of all stakeholders. If even the worst of times. Strategic action to 4Unicef, New York, USA communities and individuals are better con- tackle and prioritise support for reproductive, 5United Nations Office for Coordination of Humanitarian nected they are able to support each other, maternal, newborn, child, and adolescent Affairs, New York, USA share knowledge, and demand accountabil- health is fundamental to human dignity. Such 6United Nations Foundation, Washington, DC, USA ity of systems.22 action must be more context sensitive, Correspondence to: K Gilmore [email protected] Fourthly, accountability should be at the adapted to and for changing circumstances Additional material is published online only. To view centre of strategy. There should be a new and across the life course. The health inter- please visit the journal online (http://dx.doi. emphasis on “rolling down” accountability ventions and overall response to crises in org/10.1136/bmj.h4346) 1 Peterson, K. From the field: gender issues in disaster to local communities and individuals who humanitarian and fragile settings must be response and recovery. Natural Hazards Observer live with the effects of decisions taken else- better anticipated, planned, and resourced. 1997;21:3-4. where. This can be reinforced through adher- More than ever we need the Every Woman 2 OCHA. Overview of global humanitarian response 2014. Mar 2013. https://docs.unocha.org/sites/dms/ ence to principles of good governance and Every Child and humanitarian communities CAP/Overview_of_Global_Humanitarian_ supported by systems that enable participa- to come together, to support each other’s Response_2014.pdf. 3 Unicef. Humanitarian action for children 2014. Feb tion of all stakeholders in civil society, espe- efforts, and to work in more complementary 2014. www.unicef.org/gambia/Humanitarian_Action_ cially at local levels. ways. We need cooperation between and for_Childen_2014_Overview.pdf.

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4 United Nations Development Programme. UNDP fast 10 Save the Children. State of the world’s mothers 2014. 16 Hutton D. Older people in emergencies: considerations facts: disaster risk reduction and recovery. Apr 2014. Saving mothers and children in humanitarian crises. for action and policy development. World Health www.undp.org/content/undp/en/home/librarypage/ 2014. www.savethechildren.org/atf/cf/%7B9def2ebe- Organization. 2008. ­www.who.int/ageing/ results/fast_facts/fast-facts--disaster-risk-reduction- 10ae-432c-9bd0-df91d2eba74a%7D/SOWM_2014.PDF. publications/Hutton_report_small.pdf. and-recovery.html. 11 Inter-Agency Working Group on Reproductive Health in 17 The Atlas Alliance, CBM. Disability in conflicts and 5 Organisation for Economic Cooperation and Development. Crises. Inter-agency reproductive health kits for crisis emergencies. www.cbm.org/article/downloads/71140/ States of fragility 2015 Mar 2015. www.oecd.org/dac/ situations. 5th Edition, 2011. http://iawg.net/ Fact_sheet_Disability_in_Conflict_and_Emergencies. states-of-fragility-2015-9789264227699-en.htm. resources/184151_UNFPA_EN.pdf. pdf. 6 World Health Organization. Trends in maternal 12 WRC, Save the Children, UNHCR, UNFPA. Adolescent 18 UNFPA, http://www.unfpa.org/demographic-dividend. mortality: 1990 to 2013. Estimates by WHO, Unicef, sexual and reproductive health programs in 19 Lewis J. Continuum or contiguum? Development for UNFPA, The World Bank, and the United Nations humanitarian settings. An in-depth look at family survival and vulnerability reduction. 2001. www.dcscrn. Population Division. May 2014. www.who.int/ planning services. Dec 2012. www.unfpa.org/sites/ org/cms/uploads/esa2001/lewies%20-%20 reproductivehealth/publications/monitoring/ default/files/resource-pdf/AAASRH_good_practice_ continuum%20or%20contiguum.pdf. maternal-mortality-2013/en/. documentation_English_FINAL.pdf. 20 Enarsson E. Promoting social justice in disaster 7 World Health Organization. Levels and trends in child 13 The Partnership for Maternal, Newborn, and Child reconstruction: guidelines for gender sensitive and mortality 2014. www.who.int/maternal_child_ Health. PMNCH knowledge summary #32. Protecting community-based planning. In Gupta KR, ed. Urban adolescent/documents/levels_trends_child_ women’s and children’s health from a changing development debates in the new millennium. Atlantic mortality_2014/en/. climate. www.who.int/pmnch/knowledge/ Publishers and Distributors, 2005;25-33. 8 Oestergaard MZ, Inoue M, Yoshida S, et al. Neonatal publications/summaries/ks32/en/index1.html. 21 United Nations. The Sendai framework for mortality levels for 193 countries in 2009 with trends 14 World Bank Group. Violence against women and girls. disaster risk reduction 2015-2030. 2015. www. since 1990: a systematic analysis of progress, Lessons from South Asia. 2014. www-wds.worldbank. preventionweb.net/files/43291_sendaiframe​ projections, and priorities. PLoS Med org/external/default/WDSContentServer/WDSP/IB/201 workfordrren.pdf. 2011;8:e1001080. 4/09/15/000456286_20140915114431/Rendered/ 22 Meier P. New information technologies and their 9 Morof DF, Kerber K, Tomczyk B, et al. Neonatal survival in PDF/906000v10PUB0E00Box385314B00PUBLIC0.pdf. impact on the humanitarian sector. International complex humanitarian emergencies: setting an 15 International Center for Research on Women. Child Review of the Red Cross 2011;93:1239-63. evidence-based research agenda. Confl Health marriage facts and figures. www.icrw.org/ 2014;8:8. child-marriage-facts-and-figures. Cite this as: BMJ 2015;351:h4346

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Accountability in the 2015 Global Strategy for Women’s, Children’s and Adolescents’ Health Julian Schweitzer describes the steps taken to ensure accountability in the 2015 Global Strategy and why it is important to success

s the era of the millennium devel- accountability framework in the 2015 strat- compels a state to explain what it is doing, opment goals (MDGs) draws to a egy.1 In the absence of a comprehensive why, and how. Without prescription of exact close, each year some 6.3 million review of the accountability processes pro- domestic formulas for accountability and children under the age of 5, posed by CoIA, the group reviewed relevant redress, the right to health can be realised 289 000 women, 2.8 million new- country and global reports, including on the and monitored through various mecha- Aborns, and 1.3 million adolescents still die implementation of the 2010 strategy.4 Other nisms. At a minimum, however, all account- from preventable causes. Others experience accountability processes, such as nutrition ability mechanisms must be accessible, illness and disability, generating enormous and education, were also reviewed and are transparent, and effective. loss and costs. An additional 2.6 million cited below. Consultations were held with Administrative and political mechanisms babies are stillborn. Building on the 2010 stakeholders during 2015, including two are complementary or parallel to judicial Global Strategy for Women and Children, the review meetings with government, aca- accountability mechanisms. For instance, forthcoming 2015 Global Strategy for Wom- demic, civil society, private sector, youth, the development of a national health policy en’s, Children’s and Adolescents’ Health1 and international agency representation. or strategy, linked to work plans and partic- aims by 2030 to end these preventable ipatory budgets, plays an important role in deaths and to achieve a “grand convergence” The right to health ensuring government accountability. Indi- in health, giving every women, child, and The right to the enjoyment of the highest cators based on human rights support the adolescent an equal chance to survive and attainable standard of physical and mental effective monitoring of key health outcomes thrive. As every preventable death is an health was first articulated in the 1946 Con- and some of the processes to achieve them. affront to human rights,2 the 2015 strategy stitution of WHO. Since then, nine interna- Many groups, including health profession- has human rights at its core. It will be coun- tional human rights treaties have recognised als, play key roles.6 Policy, budget, or public try led, universal, sustainable, equity or referred to the right to health or to ele- expenditure reviews and governmental enhancing, evidence based, partnership ments of it.5 Every state has ratified at least monitoring mechanisms hold the govern- driven, and people centred. Robust, country one such treaty and has committed to pro- ment to account in relation to its obliga- led, multi-stakeholder, and participatory tecting this right through international dec- tions towards health rights. Some health accountability processes, with independent larations and domestic legislation and services have independent or internal sys- review, unified reporting, and follow-up policies. In recent years, there has been tems to receive complaints or suggestions actions at all levels will be key to monitor increasing attention paid to the right to the and offer redress. Furthermore, impact and review progress and make the necessary highest attainable standard of health—for assessments and other studies allow policy policy adjustments to ensure success.3 example, by bodies that monitor human makers to anticipate the likely and actual rights treaties, by WHO, and by the Commis- impact of policies on the enjoyment of the Methods sion on Human Rights (now the Human right to health. A working group convened by the govern- Rights Council), which in 2002 created the Political mechanisms, together with moni- ments of Tanzania and Canada (see appen- mandate of “Special Rapporteur” on the toring and advocacy by NGOs and civil society, dix) prepared proposals for the right of everyone to the highest attainable also contribute to accountability. Civil society standard of physical and mental health. organisations use indicators, benchmarks, Key messages These initiatives have clarified the nature of impact assessments, and budgetary analysis the right to health and its achievement. to hold governments and other service­ pro- We need a strong, inclusive, transparent, States have the primary obligation to respect, viders accountable. Judicial mechanisms rights based and independent protect, and promote the human rights of the can also provide remedies. Incorporation accountability process, based on people living in their territory and in turn into domestic laws of international instru- experience implementing health aspects must guarantee the right to health to the ments recognising the right to health can of human rights treaties, the MDGs, the maximum of their available resources, even considerably strengthen the scope and effec- 2010 strategy, and other health initiatives if these are tight. While steps might depend tiveness of remedial measures, by enabling All the stakeholders in women’s, children’s, on the specific context, all states must move courts to adjudicate violations by direct ref- and adolescents’ health must be engaged towards meeting their obligations to respect, erence to the International Covenant on Eco- to achieve the convergence goals of the protect, and fulfil.6 nomic, Social, and Cultural Rights.6 2015 strategy Mechanisms of accountability, crucial to Key processes and institutions at the ensure that state obligations concerning the Accountability in the 2015 strategy country, regional, and global level need to right to health are respected, take place at Accountability builds on experience gained be strengthened and supported national, regional, and international levels. over the past decades, particularly since the The 2015 strategy will create a unified They involve various contributors, such as advent of the MDGs in 2000. In addition to global accountability mechanism the state itself, NGOs and civil society, the measures described above, the 2005 Paris with links to key intergovernmental national human rights institutions, and Declaration on Aid Effectiveness called for mechanisms to ensure appropriate actions international treaty bodies. Accountability mutual accountability, with donors and

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Box 1: Bangladesh civil and vital registration—progress and challenges15 desh is an example of a country showing advances and challenges (box 1). • Public facilities in Bangladesh report deaths, and these data are available at the national level • Deaths at most non-government facilities, however, go unreported. Hospital deaths are not reported What have we learnt? to the relevant statistical agency The experience of implementing account- • Causes of death are not yet recorded/mentioned in the death register in a manner consistent with ICD- 10 (international statistical classification of diseases, 10th revision) ability frameworks arising from the human • Accuracy, completeness, and quality of recording and reporting are not always at an acceptable rights treaties, the efforts to achieve the standard MDGs, and the EWEC movement since 2010 • Community births and deaths are now reported electronically and cover the whole country provide some key messages and principles • Maternal-perinatal death review based on verbal autopsy without medical certification is in the for a rights based accountability framework. pilot phase in four districts and will be scaled up in another three districts, but resources are This is not a comprehensive list—others will insufficient emerge as the 2015 strategy is implemented • There is weak coordination between the agency responsible for statistics and the ministry of health and more evidence emerges on the impact of and family welfare (MOHFW), with both collecting data independently­ such frameworks on outcomes. • Data on fertility and mortality under statistically valid random sampling are in place and published every year The accountability framework for the 2015 • Other survey data on vital statistics are also generated by the MOHFW from time to time, but data strategy quality is a concern The accountability framework builds on • A health and demographic surveillance system providing regular and timely health data does not these lessons together with the experience yet exist in other sectors.21 22 23 The 2015 strategy will likely be launched at the same time as themselves at the receiving end of multi- the SDGs, and relevant SDG and strategy partners both accountable for development ple demands for data from donors and indicators are being aligned to minimise results.7 Since 2010, a group of countries partners overload and confusion between compet- and donors known as IHP+ (International • tracking commitments. ing data needs. Through its support for the Health Partnership) have joined together to 2015 strategy, the newly created Global provide “an independent assessment of There was no explicit reference to human Financing Facility (GFF) will also play an results at country level and of the perfor- rights. High level political leadership, pub- important role in providing additional mance of each signatory individually as lic-private partnerships, increased resources, resources for accountability.24 Efforts are well as collectively.”8 and civil society participation have contrib- under way to align the strategy account- The 2011 UN Commission on Information uted to progress, particularly on vital regis- ability framework with existing global ini- and Accountability for Women’s and Chil- tration, information, tracking of resources, tiatives, such as Family Planning 2020, to dren’s Health (CoIA), recognising the cru- and oversight.11 12 Over 50 countries have minimise additional demands for data and cial links between human rights and prepared country accountability frame- monitoring. health in human rights treaties, included a works, with WHO participation.13 framework for global reporting, oversight, Accountability principles and accountability for women’s and chil- Serious challenges remain As countries and contexts differ consider- dren’s health and the strengthening of The previously cited CoIA and iERG reports ably, a single “accountability blueprint” links with mechanisms for human rights.9 note weak national accountability mecha- would not work. Rather, based on experi- The commission recommended improve- nisms, lack of transparent data, and health ence over the past decades, the account- ments in vital ­registration, health indica- systems under pressure to deliver ambitious ability working group enunciated a core set tors, information and communications political goals, with limited worker and of accountability principles for the 2015 technology, resource ­tracking, reaching ­management capacity. “Multiple information-­ strategy: women and children, national oversight, collection systems­ have emerged, each with • adherence to human rights including the transparency, and aid reporting. An inde- its own process for tracking financial and rights of women, children, and adolescents pendent Expert Review Group (iERG) has non-financial commitments” (CoIA). “The to receive quality and respectful services reported regularly to the UN secretary gen- success of the post-2015 agenda will be • the rights of communities and civil society eral on implementing the 2010 strategy judged by the way the current rhetoric on to participate in monitoring, review, and 10 and the CoIA recommendations. The accountability is translated into mechanisms action, and 9 CoIA definition of accountability —a cycli- for robust and independent monitoring, • the key roles and responsibilities of the cal process of monitoring, review, and transparent and participatory review and different stakeholders in the health sector, action that emphasises human rights prin- effective and responsive action” (iERG). from governments and international agen- ciples of equality, non-discrimination, A preliminary assessment in 2014 by the cies, to the private sector, civil society, transparency, and partnership—is now Every Woman, Every Child (EWEC) move- and, above all, the women, children, and widely accepted in global health and will ment identified progress but also different adolescents who have the right to survive be used in this paper. dimensions of accountability that needed and thrive. strengthening.14 Weak data, such as those on Some progress births and deaths, use of resources, or quality In some cases, accountability can be The 2010 strategy had four accountability of ­services, make it more difficult to devise assigned to a single stakeholder—for exam- themes: appropriate policies and solutions and to ple, the accountability of a government to • national leadership ensure that resources are prioritised in favour provide basic health services. In other cases • country monitoring and evaluation of poor women, children, and adolescents. we are talking of mutual accountability—for • reducing the reporting burdens on poor Poor data can also result in misallocation of example, the accountability of partners in countries. These countries often find resources and inappropriate policies. Bangla- an international health partnership to

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Box 2: Designing accountability frameworks—the key messages • Focus on equity and human rights—The accountability framework, both at country and global levels, needs a firm human rights focus in the nine legally binding international treaties that address health related rights and have corresponding mechanisms to monitor implementation.5 Information needs to be disaggregated by sex, income, and geography to ensure that at risk and vulnerable populations are prioritised • Country ownership and oversight is paramount—Despite decades of efforts at harmonisation, there are still parallel initiatives and data demands by the development partners and sometimes by different country agencies.8 As ever increasing proportions of financing come from domestic resources, the demand for data, review, and action must be home generated, researched, and owned. Countries such as Tanzania, Nigeria, Rwanda, and Bangladesh are developing accountability systems that focus on the local level and, in some cases, the engagement of civil society. Other countries have issued targets, such as birth attendance by a skilled provider, which can be tracked by civil society13 • Don’t forget the “health enhancing” sectors—A recent study highlighted the large contribution of “non-health” sectors (such as water and sanitation, girls’ education, etc) to health outcomes for women and children.3 These sectors need to be engaged—for example, through process indicators measuring the extent of partnership between the relevant ministries and agencies. Indicators that directly measure issues such as access to clean water and sanitation can be used as important proxy indicators for maternal and newborn health • Value for money—Those countries that have achieved the health MDGs also achieved better value for money and targeting of resources, as well as spending more16 17 • Include and engage the private non-profit and for profit sectors that provide the bulk of health services and even financing in many countries, but have been largely ignored in the accountability debate • Engage communities and civil society18 —Civil society and local communities must be engaged in issues that affect them and their decision making—for example, on spending priorities and access to and quality of healthcare. Participation is a critical element of a rights based approach. A randomised control trial in Uganda found that community based monitoring had a profound effect on quality and uptake of services and outcomes.19 Other community based mechanisms include assessments of the impact on human rights, reviews of maternal death, health tribunals, and local and traditional courts20 • At sub-national levels there needs to be a focus on diverse settings—so that, for example, “hot spots” in areas of high need and/or areas with lack of services are highlighted and large geographical and social inequities in health outcomes can be addressed • The accountability process needs to be transparent, freely accessible, and independently verifiable, with open access to data and scorecards • International agencies need to ensure mutual consistency of their data • To avoid confusion and overload at the country level, the 2015 strategy indicators will be aligned with the SDG health goals and indicators and broader SDG goals and indicators that have an impact on health • Finally, there need to be much stronger linkages between the three parts of a rights based accountability framework: monitoring, review, and remedial action

Box 3: Global Strategy 2015 accountability principles • The purpose, functions, and deliverables of the accountability mechanism in terms of a dynamic process of monitoring, review, and remedial actions must be clear, transparent, and inclusive of all stakeholders • Social accountability—defined as an approach towards building accountability that relies on civic engagement, in which ordinary citizens and/or civil society organisations participate directly or indirectly in exacting accountability25—is critical. Evidence of the impact of social accountability in Uganda has been previously cited • Accountability mechanisms should embody health rights (including sexual and reproductive rights) and equity with appropriate reference­ to human rights instruments and treaty monitoring bodies. In this regard the rights of adolescent girls to receive access to quality sexual and reproductive health services are paramount. the 2015 strategy accountability processes must therefore be coordinated with other accountability processes, including human rights, enacted by UN and intergovernmental institutions and be aligned with SDG accountability processes • The highest levels of political authority, including government leaders, parliaments, intergovernmental processes, representative bodies such as the Inter- Parliamentary Union, regional and global bodies, and assemblies such as the African Union and the World Health Assembly, must also be engaged, as must national and sub-national institutions, particularly in devolved governments. All are crucial to ensure that the findings of the accountability process are used to shape subsequent investments, budgets, policies, and programmes • Accountability mechanisms should, if possible, be independent. Both real and perceptions of conflict of interest should be avoided. Accountability mechanisms should have established procedures to enable open and transparent engagement with key constituencies • Regular and open reporting: data, scorecards, reports, etc, should be accessible, usable, and verifiable by civil society, communities, and researchers. Monitoring should increasingly focus on outputs/outcomes, rather than inputs. Monitoring is not just about data but includes qualitative issues and adherence to rights. Monitoring of accountability processes and engagement of key parties is also important • National reviews should span the various administrative levels where services are delivered and should be linked to relevant national and sub-national planning and budget cycles. This will be facilitated though strengthening capacity for participatory monitoring and accountability at the local, sub-national, and national levels • The institutions carrying out the accountability process should collect data from various sources. Health systems data as well as independent (for example, citizen collected) data on access, quality, and equity of health services should be reviewed • Resources: the accountability mechanism should be appropriately resourced • Monitoring impact: the accountability mechanism themselves should be regularly reviewed.

mutually deliver agreed services. These core enabling environments). It will have broad This is a comprehensive agenda, and it will principles will themselves need regular coverage in six strategic areas: be critical to avoid overloading already review to ensure their continuing applicabil- • advancing country leadership stressed country data and information sys- ity and ­relevance. • maximising agency and potential tems with demands for additional data.9 • strengthening health systems Comprehensiveness, to ensure that policies, Balancing completeness and overload • promoting community engagement budgets, and services for women, children, The goals of the 2015 strategy are to survive • enabling cross sector collaboration, and and adolescents can be adequately moni- (end preventable deaths), thrive (ensure • improving healthcare in humanitarian tored (including by the recipients of these improved health), and transform (expand settings. services), has to be balanced against

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Accountability—monitoring, review, and remedial action21 rights, adolescence, and contributions from non-health sectors, disaggregated by Monitoring—regular, timely, good quality, transparent, international Review—inclusive, transparent, Act—evidence based, income, sex, and location. standards multiple inputs transparent, timely Despite progress, there are still countries Country with weak or non-existent civil registration Data collection; annual performance Health sector, civil society, academic Government budgets, plans and vital statistics systems, national health reports and scorecards; special and other reviews; media reports; and programmes; civil society studies; CSO and academic reports; parliamentary committees, country and private sector budgets, accounts, health management information, social accountability reports level independent review bodies plans and programmes, and other data systems crucial for determin- participatory budgeting and ing progress. Processes for review and reme- policy planning dial action can also be weak, with limited Regional Regional monitoring report and (Sub)regional country peer review Country action; regional engagement with civil society and commu- scorecards (such as Africa Health mechanisms; regional UN reviews initiatives nity. The 2011 CoIA recommendations on Stats, CARMMA, ALMA, Africa Health (such as WHO regional committee, strengthening country capacity3 therefore Budget Network, Arrow); social UN regional commission); regional accountability reports groups such as African Union need to be fully implemented, together with Global assistance to develop capacity for monitor- UN monitoring reports; CSO, academic Such as UNGA, WHA, PPD, IPU; Country action; global ing, evaluation, research, and advocacy, so reports (such as Countdown); expert groups; stakeholder groups; initiatives and advocacy; that the outcomes of the accountability pro- commitment /expenditure reviews; “open” mechanisms funding decisions social accountability reports; annual/ cess can be translated into policy and action. biannual “state of RMNCAH” review Whatever the system of government, a base- CARMMA=Campaign on Accelerated Reduction of Maternal Mortality in Africa, ARROW=Asia-Pacific Research and line standard of reporting is planned so that Resource Center for Women, ALMA=Africa Leaders Malaria Alliance, UNGA=United Nations General Assembly, WHA=World progress can be compared across countries Health Assembly, PPD=Partners for Population Development, IPU=Inter-Parliamentary Union, UNGA=UN General Assembly, WHA=World Health Assembly, CSO=Civil Society Organization, RMNCAH=Reproductive, Maternal, Newborn, and regions. The global accountability sys- Child, Adolescent Health. tem depends on accurate data from coun- tries and is only as good as the sum of its country parts. ­feasibility, reliability, affordability, function- of health finance and delivery, the public-pri- ality, and access to data systems and their vate interface, legal statutes, parliamentary Regional mechanisms links with the broader SDG system (table). oversight, the role of audit bodies, etc. The Key regional country groupings and organisa- 2015 strategy accountability framework has tions play a major role with regional peer mech- Country accountability to build on these processes while incorporat- anisms to review progress and propose remedial Country governance and accountability pro- ing a complex range of data on health out- action. Regional bodies will be essential to con- cesses depend on factors including comes, service delivery, health finance and nect and reinforce linkages between global and the degree of centralisation/decentralisation expenditures, social determinants, human national mechanisms – facilitating monitoring

Country accountability Global accountability UN monitoring reports Expenditure reports OECD-DAC reporting

M R o r e n o v it ie it o n w t r o c Health sector reviews Global strategy SDGs high level A Data collection M Parliamentary committees Special studies independent advisory political forum Citizen hearings Social accountability panel/data hub World Health Financial and performance reports Regional State of the world’s Assembly audits Score cards reports RMNCAH Maternal and child death ColA recommendations audits ColA recommendations Country reports/ Report cards

Country plans Government CSOs Private sector Global initiatives Development partners Commitments ColA recommendations Advocacy

Review Act

Regional peer Social accountability reports review CSO reports Academic reports

Country and global accountability processes in the 2015 strategy

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through regional web platforms (such as Afri- African Union, the Partnership for Popula- 8 Mutual accountability. IHP+, 2014. www. internationalhealthpartnership.net/en/key-issues/ canHealthStats.org, CARMMA, ALMA, African tion and Development, and UN regional eco- mutual-accountability/. Health Budget Network, ARROW) supporting nomic offices also need to be engaged to 9 Keeping promises measuring results. CoiA, 2011. www. peer learning and review through regional ensure that the accounta­bility reports are who.int/topics/millennium_development_goals/ accountability_commission/Commission_Report_ meetings such as African Health Ministers, UN widely disseminated, ­discussed, and acted advance_copy.pdf. regional commissions, etc, and enabling action on by key decision makers at the national 10 WHO. Every Women Every Child, from commitments to action, the first report of the independent Expert with support for countries­ to act on recommen- and international levels. Advisory Group on Information and Accountability for dations and recognition of countries that have Contributor and sources: The author is senior fellow at Women’s and Children’s Health, 2012 exhibited progress and success. Results for Development Institute. The article is based 11 CoIA. Accountability for women’s and children’s health. on the work carried out over the past few months by the WHO, 2014. www.who.int/woman_child_ accountability working group for the 2015 strategy, accountability/about/COIA_report_2014.pdf. Global mechanisms co-chaired by the governments of Tanzania and Canada, 12 iERG. Every Woman Every Child, a post-2015 vision. WHO, 2014. http://apps.who.int/iris/bitstream/ of which the author was a member, together with Since 2010, various agencies, including the 10665/132673/1/9789241507523_eng.pdf?ua=1. subsequent consultations organised by the Every iERG, CoIA, Countdown to 2015, and the 13 Country accountability framework (CAF) assessment Woman Every Child Movement for this strategy. and maps. WHO, 2015. www.who.int/woman_child_ Partnership for Maternal, Newborn, and Competing interests: I have read and understood BMJ accountability/countries/framework/en/. Child Health (PMNCH), have reported on policy on declaration of interests and have no relevant 14 Godwin P, Misra S. The Every Woman Every Child achievements of the global strategy and interests to declare. health-model of accountability on the post 2105 era. www.who.int/pmnch/about/governance/ highlighted issues for global attention. Each Provenance and peer review: Not commissioned; not partnersforum/2b_godwin_misra.pdf?ua=1. externally peer reviewed. accountability process, however, has had 15 Country accountability framework: scorecard. The author alone is responsible for the views expressed Bangladesh. www.who.int/woman_child_accountability/ separate mechanisms, with inadequate link- in this article, which does not necessarily represent the countries/BGD_roadmap_final_web.pdf?ua=1. age between them and weak follow-up views, decisions, or policies of WHO or the institutions 16 Stenberg K, Axelson H, Sheehan P, et al; Global actions. Global accountability for the imple- with which the author is affiliated. Investment Framework for Women’s and Children’s Health. Advancing social and economic development

mentation of the global strategy will there- Julian Schweitzer senior fellow, Results for Development by investing in women’s and children’s health: a fore be brought together under a unified Institute, 1100 15th Street, Washington, DC 20005, USA new Global Investment framework. Lancet On behalf of the Expert Consultative Group for Every 2014;383:1333-54. mechanism that will prepare an annual 17 A global financing facility in support of every woman Women Every Child on Accountability report on the “State of Women’s, Children’s, every child. WHO, UNICEF, UNPOP and World Bank, Correspondence to: J Schweitzer 2014. and Adolescents’ Health.” The Partnership [email protected] 18 Updating the global strategy for women’s, children’s and for Maternal, Newborn, and Child Health Additional material is published online only. To view adolescents’ health. Back ground paper on accountability. (PMNCH) will play a key coordinating role, please visit the journal online (http://dx.doi. 2015. www.everywomaneverychild.org/images/03__ org/10.1136/bmj.h4248) Accountability_WP_24_March_2015-03-24.pdf. with an independent advisory panel 19 Bjorkman M, Svensson J. Power to the people: appointed by the UN secretary general to 1 Global Strategy for Women’s, Children’s and evidence from a randomized field experiment on Adolescents’ Health. Zero draft for consultation: 5 May community-based monitoring in Uganda. Q J Econ ensure greater independence in accountabil- 2015. www.everywomaneverychild.org/images/ 2009;124:735-69. ity. An agreed set of data for expenditures, Global-Strategy_Zero-Draft_FINAL_5-May-2015_A.pdf. 20 Center for Reproductive Rights. The role of human 2 Kuruvilla S, Bustreo F, Hunt P, et al. The millennium outputs, and outcomes will be used by coun- rights-based accountability in eliminating maternal development goals and human rights: realizing mortality and morbidity. Center for Reproductive tries and their development partners, with shared commitments. Human Rights Quarterly Rights, 2011. global and regional bodies providing reviews 2012;34:141-77. 21 Education for all global monitoring report. https:// 3 Kuruvilla S, Schweitzer J, Bishai D, et al. Success factors en.unesco.org/gem-report/. and facilitating remedial actions (figure). for reducing maternal and child mortality. Bull World 22 Global nutrition report. http://globalnutritionreport.org. Health Organ 2014;92:533-44. 23 UNAIDS. Thirty second meeting report. www.unaids.org/ 4 UN Secretary General. Full document: Global Strategy for Review, dissemination, and action sites/default/files/sub_landing/files/UBRAF_PCB_2014- Women’s and Children’s health. Partnership for Maternal, 2015_Matrix_16May2013GMA%20FINAL.pdf. A key lesson from the 2010 strategy was the Newborn and Child Health, 2010. www.who.int/pmnch/ 24 World Bank. A global financing facility in support of activities/advocacy/fulldocument_globalstrategy/en/. need to ensure that the accountability pro- every women, every child. www.worldbank.org/ 5 Human rights and accountability. PMNCH Knowledge content/dam/Worldbank/document/HDN/Health/ cess is linked to key intergovernmental Summary 23. www.who.int/pmnch/topics/ GFFExecutiveSummaryFINAL.pdf. mechanisms such as the World Health part_publications/KS23_human_rights.pdf?ua=1. 25 Malena, M, Forster, R, Singh, J. Social accountability, 6 The right to health. Office of the UN High Commissioner an introduction to the concept and emerging Assembly and the high level political forum for Human Rights/WHO, 2008. www.ohchr.org/ practice. World Bank Social Development Papers established for the SDGs. Multinational and/ Documents/Publications/Factsheet31.pdf. 31042, 2004. 7 Paris declaration and Accra Agenda for action. OECD, or regional representative bodies, such as 2005. www.oecd.org/dac/effectiveness/ the Inter-Parliamentary Union (IPU), the parisdeclarationandaccraagendaforaction.htm. Cite this as: BMJ 2015;351:h4248

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Prioritising women’s, children’s, and adolescents’ health in the post-2015 world Lori McDougall and colleagues set out a three point agenda for strengthening advocacy: investing in multipartner national platforms for action; innovative communication circuits to unite advocacy; and multidonor funding mechanisms to scale up advocacy efforts

Advocacy is the process of bringing evidence and information to bear on the decision and ability ince their adoption, the millen- to act in response to people’s needs. Advocacy and communication shape opinion, crystallise nium development goals (MDGs) common or shared thinking, mobilise action, and drive decision making. The result of advocacy have played a crucial role in and communication can be political will, the decision to mobilise resources, policy and planning, improving global health. The reprioritisation, and stronger accountability. MDGs raised awareness of key pri- Sorities for health and development, stimu- lessons learnt during the MDG era and to instrument for women’s, children’s, and lated policy and budget attention, and reflect the priorities of the new sustainable adolescents’ health, and then set these find- created a common agenda for action. Child development goals to be adopted by govern- ings against an analysis of gaps and chal- health was prioritised by MDG 4 calling for a ments in September 2015. lenges, which inform the main section of two thirds reduction of deaths in children How did women’s and children’s health this paper. We conclude with a three point under 5 years old, maternal health was pro- rise on the global agenda, and what can be agenda for action for advocacy and commu- moted by MDG 5a calling for a three quarters learnt about how to sustain attention beyond nications in the updated Global Strategy. reduction in maternal deaths by 2015, and 2015? What was the role of advocacy and the MDG 5b ambition was to ensure univer- communications in framing and communi- Methods sal access to reproductive health. Despite cating evidence, highlighting solutions and In the following sections, we summarise significant progress, MDGs 4 and 5 will not results, promoting joint action, and enabling the findings of three qualitative approaches be met. Other health goals, including MDG 6 voice and action among women, youth, fam- used to better understand the role and (on HIV/AIDS, malaria, and tuberculosis) ilies, and communities? impact of the updated Global Strategy for and MDG 1c (hunger), are marked by major Applying Shiffman’s health policy analy- Women’s, Children’s and Adolescents’ gaps in progress for women and children. sis framework of stakeholder power, ideas, Health, as well as lessons learnt from the Launched in 2010, the Global Strategy for context, and issue characteristics (table),7-9 initial years of the Global Strategy (2010- Women’s and Children’s Health (“Global we look at the experience of Every Woman 15). The first approach was a global stake- Strategy”) has fuelled efforts to deliver the Every Child during the past five years as a holder consultation process in late 2014 MDGs. The Global Strategy and the Every key factor in explaining the rise in promi- and early 2015 that captured the views of Woman Every Child advocacy movement nence of these issues. Going forward, we 4550 respondents.­ 10 The second was to syn- have promoted collective action, joint mes- consider how the updated Global Strategy thesise the views and conclusions from saging, and effective partnerships. These can improve its performance as an advocacy three teleconferences held during ­February efforts have led to more money, improved policies and service delivery, and a new Box 1: Every Woman Every Child: a joint platform for action focus on accountability and multi-stake- In 2010, there was a high degree of consensus and commitment among stakeholders in reaching the holder partnerships (box 1).1 2015 millennium development goals (MDGs). There was a concentration on a “continuum of care” To sustain progress beyond 2015, the approach—in which reproductive, maternal, newborn, child, and adolescent health are understood Global Strategy is being updated to build on to be inextricably linked—enhanced by integrated care across the life cycle and from home to hospital. A positive message of, “Progress is possible, it pays to invest” was adopted by partners Key messages based on best available evidence of epidemiological and economic progress. In an increasingly global public health environment of private-public alliances, the Every Woman Every Child Strengthening citizen led local action movement was launched by UN secretary general Ban Ki-moon as a common advocacy platform for is core to the mission of advocacy and diverse stakeholders to work together to implement the Global Strategy for Women’s and Children’s communication for the Global Strategy Health and the MDGs. Effective action requires investment in The pay-off has been substantial: by 2014, there were more than 300 commitments from a diverse strong coordinating platforms among range of stakeholders (figure ) through the Every Woman Every Child platform—a threefold increase diverse stakeholders, led by respected from the launch in 2010.3-5 Financial pledges have risen to nearly $60bn, with many additional, champions uncosted commitments aimed at strengthening policy, service delivery, and advocacy.2 The Global Building a robust investment case for Strategy has drawn attention not only to more resources, but to better use of those resources, brokering advocacy requires greater attention to agreement on cost effective interventions, integrated efforts for scaling up, innovation, and joint funding channels.5 developing clear performance monitoring and evaluation indicators Such global campaigns can be a timely “hook” for stimulating national dialogue and brokering Creating stronger advocacy partnerships consensus about priorities and resources. They can also be a promise of greater external coordination and resource exchange, as well as an aid to mobilising new commitments among global stakeholders. within the health domain, and between For example, the G8 Muskoka Declaration in June 2010 of an additional $5bn for maternal and child health and other related sectors, is health6 paved the way to a successful launch of the Global Strategy for Women’s and Children’s Health required to deliver the vision of the in September 2010, which itself built on years of active health advocacy and increased visibility for sustainable development goals maternal health issues.

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Framework of determinants for political priority for the Global Strategy for Women’s and Children’s Health (2010-2015) Description Factors shaping political priority Stakeholder power—The strength of Policy cohesion, leadership, guiding institutions, mobilisation of civil society—The EWEC movement, championed by UN the individuals and organisations secretary general Ban Ki-moon, brings together reproductive, maternal, newborn, child, and adolescent health stakeholders concerned with the issue working through coordinating platforms such as the H4+ multilateral agencies, PMNCH (including more than 400 NGO members), Women Deliver, the Network of Global Leaders, and the Global Campaign for the Health MDGs. Ideas—The ways in which those Positioning within the health sector and among health and related sectors—The adoption of a RMNCAH “continuum of care” involved with the issue understand conceptual model has facilitated consensus across diverse policy constituencies, including governments, NGOs, health and portray it professionals, donors, private business, the UN, and academia. Positioning is important to ensure women’s and children’s health is seen as a human right as well as a determinant, outcome, and indicator of economic, social, and political development. Political contexts—The environments Policy windows, global governance structure, convening and driving the process—The 2015 MDG framework, with twin goals on in which stakeholders operate maternal and child health, opens policy window for urgent action. The Global Strategy legitimised as an agenda for national and regional action through inter-governmental resolutions and communiqués (UN 2010, World Health Assembly 2011, UN Human Rights Council on maternal mortality 2011, Inter-Parliamentary Union 2012) and frameworks (African Union integrates Global Strategy into policy frameworks, building on Maputo Plan of Action for SRHR, CARMMA, and Abuja Declaration). Issue characteristics—Features of Credible data, evidence of gaps (severity of the problem), effective interventions available—Robust evidence on causes, the problem solutions, trends, and gaps increasingly available through a wide range of sources, including Countdown to 2015, UN reports, Lancet special series, and others. Multi-stakeholder consensus on effective interventions brokered at global level, offering clear policy directions. EWEC=Every Woman Every Child. PMNCH=Partnership for Maternal, Newborn & Child Health. NGO=non-governmental organisation. MDG=millennium development goal. RMNCAH= reproductive, maternal, newborn, child and adolescent health. SRHR=sexual and reproductive health and rights. CARMMA=Campaign for Accelerated Reduction of Maternal Mortality in Africa.

and March 2015 with advocacy leaders of Lack of awareness and ownership of processes, are critical for ensuring monitor- the women’s and children’s health commu- national commitments ing, review, and remedial action. Civil soci- nity and those who contributed to the While engagement with the Global Strategy ety coalitions at sub-national, national, Global Strategy consultation process. has been consistently strong among global regional, and global levels can gather evi- Thirdly, we conducted a literature search level stakeholders, at the country level it has dence for multi-stakeholder review pro- on definitions, theories, and examples of been more variable. For example, in the first cesses and recommend remedies (see box 2). ­successful advocacy and communications consultation report on the 2010-15 Global A large scale stakeholder survey on the practice as well as relevant conceptual Strategy published in January 2015, respon- Global Strategy (April 2015) found that more frameworks for agenda-setting and dents at country level commented that lack than 80% of respondents thought that global issue-framing. The literature search of country engagement with the Global Strat- accountability did not affect country level enabled us to expand on the findings of the egy was an important limitation (see www. processes. This indicates a clear role for expert consultations and triangulate our womenchildrenpost2015.org). Important local, citizen led processes.10 own observations. national stakeholders, including parliamen- tarians, have been unaware of pledges made Stronger monitoring and evaluation for Problems by their country. This has inhibited their advocacy impact The implementation of the Global Strategy ability to engage with relevant policy and Effective advocacy is the product of a com- has been marked by challenges that have budget planning. plex mix of actors, context, and opportunity, inhibited civic leadership and national Many national stakeholders lack access to making the impact of individual contribu- ownership, and implementation of the top relevant platforms for policy dialogue and tions difficult to measure.11 Even so, advo- priorities identified within the strategy information sharing. Sub-national and cates benefit from robust monitoring and itself. Three of these challenges are national accountability systems, if rigor- evaluation approaches to assess progress ­discussed. ously monitored and connected to global and improve practices.4 Two specific prob-

Box 2: Stakeholder power drives issue attention: citizen led coalitions Tanzania The White Ribbon Alliance for Safe Motherhood Tanzania united civil society members, health professionals, academics, donors, and UN partners in a three year (2013-15) campaign to improve access to comprehensive emergency obstetric and newborn care (CEmONC) at health centres and with the help of qualified health workers. The campaign calls for a specific budget line item with funds for CEmONC in Tanzania’s council health plans. As a result of tactical outreach aimed at communicating the gaps in access to CEmONC and its major causes (poor financing for CEmONC), media campaigning, and one-on-one meetings with key champions, the prime minister of Tanzania on the White Ribbon Day (15 March 2014) gave a directive that all councils establish a budget line for CEmONC with funds to ensure that these lifesaving services are available at health centres. The campaign has also yielded a petition on CEmONC signed by 16 428 citizens and 96 members of parliament. Nigeria In support of improving accountability and aid alignment, including in relation to maternal and child health, CHESTRAD International and the IHP+Results Consortium worked with Nigeria’s Senate Committee on Appropriations and the National Planning Commission to document the flow of official development assistance (ODA) into health and education and recommend improvements in managing aid flow. This report led to a parliamentary multi-stakeholder dialogue hosted by the Senate and Nigeria’s Federal Ministry of Finance and the National Planning Commission, with participation from development partners and civil society. The dialogue resolved to better align ODA flows with appropriation processes, expand efforts at inclusive national budgeting and transparency, and establish a civil society aid effectiveness and accountability fund. This process also catalysed the creation of a new parliamentary committee on coordination and engagement with development partners in Nigeria. Data sources: Partnership for Maternal, Newborn & Child Health. Progress report. Budget advocacy for improved women’s and children’s health: experiences from national civil society coalitions. 2013. www.who.int/pmnch/media/events/2013/progress_report.pdf?ua=1 Statement: parliamentary stakeholder dialogue on aid effectiveness and results. National Assembly Complex, Abuja, Nigeria 16-17 May 2011. ­www. internationalhealthpartnership.net/fileadmin/uploads/ihp/Documents/Country_Pages/Nigeria/StatementParliamentaryDialogue-25.05.2011.pdf

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rier to participating in multi-stakeholder Private sector platforms for reproductive, maternal, new- born, child, and adolescent health (see, for Academic and research % institutions example, http://chestrad-ngo.org/communi- % cations/publications-reports/). Yet relatively Non-governmental Healthcare professional organisations associations few donors fund such advocacy, especially at  % % national level. Governments often prefer not % Low income countries to make investments that could put them in % % the “line of fire.” Middle income countries A review of progress of Global Strategy % % High income countries commitments made between 2010 and 2013 % found that reproductive, maternal, newborn, Foundations and child health organisations were often Global partnerships Multilateral organisations understaffed. This resulted in a limited capacity for advocacy because of poor staff Advocacy commitments for the Global Strategy for Women’s and Children’s Health by constituency training and reluctance by donors to fund (data from the PMNCH 2013 report2) advocacy and related staff positions. The financial crisis of 2008 and the subsequent lems (both vital ingredients for success) are, Tracking impact—In regard to evaluating poor economic climate further destabilised firstly, the availability of adequate data and the effect of advocacy, the lack of standard funding for advocacy and thus the ability of evidence with which advocates can take indicators, processes, and structures for partners to conduct advocacy.2 action and, secondly, robust methods for monitoring and reviewing the Global Strat- tracking advocacy impact. egy and Every Woman Every Child has hin- Priority actions Data and evidence—While the MDGs and dered efforts to improve quality and impact. Successful advocacy in the post-2015 era the Global Strategy have been useful tools It has also made it more challenging to build will depend on the ability to identify how for advocacy, the lack of costed implementa- an investment case for advocacy. For exam- investments can deliver multiple goals tion plans and consolidated mechanisms for ple, while it is relatively simple to measure across sectors, including in complex set- tracking resources and results have ham- “interim” or “process” indicators, such as tings such as during a humanitarian emer- pered its effectiveness. Greater transparency the number of commitments made or media gency or conflict, where ill health is of government data and information, sup- hits (box 3), it is often difficult to determine disproportionately clustered. This section ported by stronger national data collection the extent to which a particular activity by a sets out a three point agenda for effective systems, will benefit advocacy efforts, as particular stakeholder or coalition contrib- advocacy and communications around the would greater emphasis on community utes to broader national impact on policies Global Strategy beyond 2015. based efforts to improve accountability. or budgets. Examples of this policy effort are the Invest in national multi-stakeholder national and sub-national “citizen hearings” Scaling financing for advocacy platforms for advocacy and accountability bringing stakeholders and policymakers Underfunding remains a barrier to success- Uniting partners with disparate skills, disci- together in policy dialogue (see also: http:// ful advocacy. A recent survey of civil society plines, epistemic traditions, and networks whiteribbonalliance.org/campaigns/­citizens- organisations in Africa indicated that lack of for joint advocacy and providing these advo- hearings-2015/).12 financing was the most commonly cited bar- cacy networks with timely information about commitments is critical to ensuring the implementation of the Global Strategy. This Box 3: Measuring media impact: Born Too Soon requires investment in leadership, coordina- Media advocacy can promote consensus on framing and solutions, generate attention on policy, tion, and communication skills at all levels. and prompt united action among different stakeholders. An example is the 2012 launch of Born Too In 2012-13, for example, the Partnership for Soon: The Global Action Report on Preterm Birth, which highlighted preterm birth as the leading cause of newborn mortality. A communications campaign coordinated by the Partnership for Maternal, Maternal, Newborn & Child Health provided Newborn & Child Health brought together more than 50 partner organisations to advocate for attention a small level of support for national coali- to preterm birth. This included civil society groups such as the March of Dimes, corporations such as tions of civil society organisations in 10 coun- Johnson & Johnson, and health professional groups such as the International Paediatric Association, tries. This enabled joint advocacy and the International Confederation of Midwives, and the International Federation of Gynecology and improved accountability, including for Obstetrics. national commitments to the Global Strategy. The campaign reached an estimated media audience of 1.1 billion through the Hindu, the Xinhua In most of the participating countries, these news agency, the front page of the New York Times, and others. This was complemented by a television are the first coalitions of civil society organi- advert on CNN International with celebrity singer and parent Celine Dion, as well as a global Twitter sations to cover the entire continuum of care “relay” and an interactive map on which Facebook members could “pin” their own stories of preterm from preconception to child and adolescent birth. In total, Born Too Soon resulted in more than 30 new Every Woman Every Child commitments to health. The partnerships have resulted in a preterm birth and newborn health. It catalysed the expansion of World Prematurity Day, with events in 70 countries in 2014. It also set the foundation for a broader policy effort, the Every Newborn Action number of innovative approaches, such as a Plan, supported by a resolution by 194 member states of the World Health Assembly in 2014. joint advocacy toolkit in Tanzania to increase the enrolment of youth in midwifery training; Data sources: in Ghana, Indonesia, and Uganda, voluntary March of Dimes, Partnership for Maternal Newborn & Child Health, Save the Children, World Health contribution schemes have been created to Organization. Born Too Soon: the global action report on preterm birth. WHO, 2012. cover the cost of alliance activities.13 Howson CP, Kinney MV, McDougall L, Lawn JE. Born Too Soon: preterm birth matters. Reprod Health The most successful of these coalitions 2013;10:S1. have established relationships with parlia-

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Box 4: Ideas drive attention to issues: London summit and FP2020 health. Without such national and sub-na- Family planning was framed in the Global Strategy as an important issue for investment and policy, tional advocacy, the GFF ambitions are creating a new hook for advocates to align and take action. A good example of this is the Family unlikely to be fully realised. It is import- Planning 2020 (FP2020) initiative, which has emerged from the London Summit on Family Planning ant, therefore, for the GFF facility to sup- in 2012. The summit gained commitments from more than 20 governments and donor funding of port national advocacy, both in principle $2.6bn, elevating political commitment to modern contraceptives and reproductive health in support and in fact. of the wider remit of the Global Strategy. Since 2013, more than $1.3bn has been disbursed for family planning programmes. This has resulted in more than 8.4 million extra girls having access to Conclusion modern contraception and at least 77 million unintended pregnancies avoided. The FP2020 example Advocacy and communication matter not for illustrates how global and national health advocacy fosters and builds on widespread agreement on the urgency of an issue. their own sake but because they are essential in facilitating the social and political pact Data source: Family Planning 2020 (FP2020). www.familyplanning2020.org. that drives forward the Every Woman Every Child movement. ments and the media. In many countries in Plan of Action on Sexual and Reproductive There are important lessons from the Asia and Africa, private media are a major Health and Rights and the Abuja Call for recent Global Strategy experience, especially growth industry. The media can be a pow- Accelerated Action Towards Universal Access in promoting country ownership and engag- erful platform for voice and accountability, to HIV and AIDS, Tuberculosis and Malaria ing with national and regional policy pro- capturing public energy and anger, and Services in Africa (see Africanhealthstats.org cesses. Stronger evidence is needed about shifting cultural norms. Yet, too often, the and http://carmma.org/scorecards for more what works in advocacy, why it works, and media are seen as a target for pre-packaged information). When geared to local needs how to measure and improve advocacy in the public relations campaigns and not as via- and priorities, and properly promoted for future. The updated Global Strategy provides ble partners with essential networks and use, innovative web and mobile phone based an opportunity to further that learning and skills. Investment in partnerships with approaches hold much promise, including in apply new techniques. leading national and regional media net- relation to advocacy, communication, and Going forward, advocacy success must be works, especially those focused on young coalition development.10 measured not by the quantity of global com- media consumers, is an essential area for mitments taken in the name of citizens and development. Social and behavioural Build flexible, multidonor funding countries, but the extent to which people change campaigns that stimulate positive mechanisms for advocacy themselves demand to be at the centre of the individual behaviours, as well as positive Effective advocacy requires reliable yet flexi- dialogue, insisting on their right to monitor, changes within policy environments, are ble financing to capture sudden and unex- review, and act upon that to which they are important ways of promoting community pected opportunities as well as to address entitled. health and improving policy impact.14 longer term strategic goals. In the past, We thank Helga Fogstad of Norad, Megan Gemmell of Beyond 2015, these advocacy networks donor funding for advocacy has too often the Executive Office of the UN secretary general, Andres de Francisco, and Ahmad Azadi and Veronic Verlyck of will need to integrate partners from health prioritised individual strategic plans, miss- PMNCH for discussion and analysis contributing to this enhancing sectors, including those ing an opportunity to invest in broad based article. Alice Gilbert of CEPA provided valuable research engaged in education, women’s political coalitions supporting collective goals. contributions. and economic participation, access to Recent promising efforts include the multi- Contributors: LM and AS conceived this article as co-leads of the advocacy and communications clean water and sanitation, poverty reduc- donor “Amplify Change” fund for sexual and workstream of the Global Strategy process. JF-V, AEB, LM, tion, and economic growth in line with the reproductive health and rights, as well as and KT drafted this article based on a literature search evidence of the importance of these sectors support to the Every Woman Every Child and consultation with technical experts. KA, AS, AB-B, 15 LD, FD, KE, CGR, LG, KI, SK, AM, BM, and SP contributed on health. movement from such donors as the Bill & examples or reviewed drafts, or both. LM is guarantor of Melinda Gates Foundation, Canada, Norway, the article. Build digital platforms for knowledge and and the Rockefeller Foundation. Competing interests: We have read and understood the action Experience from the global nutrition com- BMJ policy on declaration of interests and have no relevant interests to declare. Advocacy operates in real time. National, munity also bears out the benefits of pooled The authors alone are responsible for the views regional, and global advocacy coalitions financing mechanisms. For example, pooled expressed in this article, which does not necessarily require timely, cost effective information donor funding for civil society partners as represent the views, decisions, or policies of WHO or the “circuits” to source new evidence for part of the multipartner trust fund for the institutions with which the authors are affiliated. action and to identify new opportunities SUN (Scaling Up Nutrition) movement has Provenance and peer review: Not commissioned; externally peer reviewed. for advocacy. enabled greater coordinated action. Of the 33 Lori McDougall senior technical officer, policy and Improving the circulation of information established and active SUN civil society alli- advocacy1 increases the effectiveness of transnational ances in countries, 27 are funded through Anita Sharma senior director2 advocacy. This is likely to be especially true this trust fund or by bilateral donors (see Jennifer Franz-Vasdeki consultant1 beyond 2015, as the number and distribution http://scalingupnutrition.org/the-sun-net- Allison Eva Beattie consultant1 of partners seeking to collaborate across sec- work/civil-society-network). Kadidiatou Touré  technical officer1 tors increases. Regional platforms can pro- In line with the goals of Every Woman Kaosar Afsana director3 vide relevant support in this process. For Every Child, the new Global Financing Amy Boldosser-Boesch interim president and chief 16 instance, the African Union/CARMMA (Cam- Facility (GFF) is designed to encourage executive officer4 paign on Accelerated Reduction of Maternal, increased commitments of domestic Lola Dare president5 17 Newborn and Child Mortality in Africa) has resources for health. This is a promising Flavia Draganus communications and advocacy developed scorecards of indicators and a user development, requiring multipartner manager6 friendly online database of indicators, help- domestic budget advocacy, including with Kate Eardley senior health policy adviser7 ing member states track progress towards media and parliamentarians, to ­mobilise Cecilia Garcia Ruiz director of gender programmes8 regional commitments such as the Maputo and ­sustain domestic allocations for Lars Gronseth senior adviser9

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Katja Iversen chief executive officer10 1 Every Woman Every Child. www. 11 Harvard Family Research Project. A guide to measuring everywomaneverychild.org. advocacy and policy. www.hfrp.org/evaluation/ Shyama Kuruvilla senior strategic adviser11 2 Partnership for Maternal, Newborn & Child Health. The the-evaluation-exchange/issue-archive/ Allison Marshall senior advocacy adviser12 PMNCH 2013 report: analysing progress on advocacy-and-policy-change/a-guide-to-measuring- commitments to the Global Strategy for Women’s and advocacy-and-policy. Betsy McCallon executive director13 Children’s Health. 2013. www.who.int/pmnch/ 12 Papp SA, Gogoi A, Campbell C. Improving maternal Susan Papp director of policy and advocacy10 knowledge/publications/2013_pmnch_report/en/. health through social accountability: a case study 1The Partnership for Maternal, Newborn & Child Health, 3 United Nations. Global Strategy launched by United from Orissa, India. Global Pub Health Nations. http://wwwunorg/press/en/2010/­ 2013;8:449-64. World Health Organization, 1211, Geneva 27, dev2827dochtm. 13 Partnership for Maternal, Newborn & Child Health. Switzerland 4 Partnership for Maternal Newborn & Child Health. The Strengthening national advocacy coalitions for 2Millennium Development Goals Initiatives, UN PMNCH 2014 report: tracking financial commitments to improved women’s and children’s health. 2013. www. Foundation, Washington, DC 20006, USA the Global Strategy for Women’s and Children’s Health. who.int/pmnch/knowledge/publications/cso_report. www.who.int/pmnch/knowledge/publications/2014_ pdf?ua=1. 3Health, Nutrition & Population, BRAC, Dhaka, pmnch_report/en/. 14 Abroms LC, Maibach EW. The effectiveness of mass Bangladesh 5 United Nations. Saving lives protecting futures: progress communication to change public behavior. Ann Rev 4Family Care International, New York, NY 10006, USA report on the Global Strategy for Women’s and Children’s Pub Health 2008;29:219-34. Health 2010-2015. www.everywomaneverychild.org/ 15 Partnership for Maternal, Newborn & Child Health. 5CHESTRAD International, Ibadan, Nigeria images/EWEC_Progress_Report_FINAL_3.pdf. Success factors for women’s and children’s health: 6Every Woman Every Child, UN Foundation 6 Government of Canada. The Muskoka Initiative: policy and programme highlights from 10 fast-track background. http://mnch.international.gc.ca/en/ countries. 2014. www.who.int/pmnch/knowledge/ 7World Vision International, Middlesex UB11 1FG, UK topics/leadership-muskoka_background.html. publications/success_factors_highlights.pdf?ua=1. 8Espolea, Mexico City, Mexico 7 Shiffman J. Issue attention in global health: the case of 16 World Bank. Global financing facility in support of Every 9Global Health, Education and Research, Norad, Oslo, newborn survival. Lancet 2010;375:2045-9. Woman Every Child. 2015. www.worldbank.org/en/ 8 Shiffman J. A social explanation for the rise and fall of topic/health/brief/global-financing-facility-in- Norway global health issues. Bull World Health Organ support-of-every-woman-every-child. 10Women Deliver, New York, NY 10012, USA 2009;87:608-13. 17 World Bank. Development partners support the 11Family, Women’s and Children’s Health, World Health 9 Shiffman J, Smith S. Generation of political priority for creation of global financing facility to advance global health initiatives: a framework and case study of women’s and children’s health. 2014. www.worldbank. Organization maternal mortality. Lancet 2007;370:1370-9. org/en/news/press-release/2014/09/25/ 12International Planned Parenthood Federation, London 10 Partnership for Maternal Newborn & Child Health. development-partners-support-creation-global- SE1 3UZ, UK Consultations on updating the Global Strategy for financing-facility-women-children-health. Women’s, Children’s and Adolescents’ Health: Round 13The White Ribbon Alliance, Washington, DC 20036, 1- Priorities for the Global Strategy. www.who.int/ USA pmnch/activities/advocacy/globalstrategy/2016_2030/ Cite this as: BMJ 2015;351:h4327 Correspondence to: L McDougall [email protected] gs_round1_report.pdf?ua=1

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