Wake-up call: 10 years remaining to address inequalities on right to health for all

This article is part of the Leaving no woman, no child and no adolescent behind collection published by The BMJ and proposed by Countdown to 2030 for Women’s, Children’s and Adolescents’ Health and the Partnership for Maternal, Newborn and Child Health (PMNCH) hosted by the World Health Organization. 

The millennium development goals sought to create a global movement to achieve targets in key areas of health and development. The problem is, we failed to reach most of them.1 Among those missed were important health related targets: reductions in undernutrition, mortality in children under 5, maternal mortality, and incidence of HIV, malaria, and tuberculosis as well as improvements in reproductive health. Inequalities between women and men and uneven progress between wealthy and poor populations largely account for the failure.

The sustainable development goals (SDGs) provide a second opportunity to improve health outcomes around the globe.2 If current trends persist, however, we will miss the mark again. For example, although we have achieved progress in reducing under 5, neonatal, and maternal mortality in the past two decades, in recent years maternal mortality has been stagnant in many high burden countries and neonatal mortality has declined at a slower pace.3 4

This collection from The BMJ and BMJ Global Health shows the improvements we have made in expanding the coverage of key interventions in sexual, reproductive, maternal, newborn, child, and adolescent health and highlights our ongoing challenges. For example, progress has slowed in immunisation and the treatment of childhood illnesses such as pneumonia and diarrhoea, and little progress has been made on curbing gender based violence. An overall lack of data is a further barrier, inhibiting our ability to make evidence based investments in healthcare systems.

Although delivery of these key health interventions is largely based on improving primary healthcare services, overall we are still far behind our goal of achieving universal health coverage (UHC).5 This means that we are missing opportunities for delivering an integrated package of prevention, care, and treatment and further advancing progress. The question is, why?

Political commitments have been made, most recently at the 2019 United Nations General Assembly, when all 193 UN member states approved the political declaration on UHC. In November, the Nairobi summit marking 25 years since the landmark Cairo International Conference on Population and Development galvanised commitments from member states and other stakeholders to achieve universal access to sexual and reproductive health and rights as part of UHC. A few weeks later, at the Inter-Parliamentary Union assembly in Belgrade, legislators from 140 countries committed to harnessing the power of parliaments to make UHC a reality. These commitments follow a long list of high level political declarations made in recent years for improving primary healthcare, particularly for women, children, and adolescents.

Yet progress in translating them to action on the ground has been slow. The reasons are many: insufficient national leadership and funding; not enough emphasis on primary healthcare and building a strong referral system to upper levels of care; and not nearly enough resources devoted to providing such essential building blocks as infrastructure (especially basic water and sanitation in health facilities), sufficiently trained and paid healthcare workers, and the adequate delivery of essential medicines and supplies. Finally, we have made insufficient use of data to monitor implementation, meaning that we may be putting our efforts and money into activities that have little or no impact because they are not delivered with a high level of quality and consistency.

With the Global Action Plan for Healthy Lives and Wellbeing for All,6 we have a unique opportunity to accelerate progress on the SDGs and tackle many of the critical challenges that are identified in this collection. Under this new approach, 12 multilateral agencies that channel one third of development assistance for health will strengthen their collaboration to support countries to accelerate progress in key areas such as primary healthcare, sustainable finance, determinants of health, data and digital health, innovation, communities, humanitarian contexts, and gender equality. The agencies will also align their operational and financial policies and jointly account for progress.

The SDG action plan builds on existing collaborative approaches such as the H6 partnership,7 which brings together five health related UN agencies and the World Bank Group to provide technical support to countries in their efforts to improve the survival, health, and wellbeing of every woman, newborn, child, and adolescent. It also supports countries in mobilising additional domestic and other resources for health.

A major part of the solution is to continue our work to expand primary healthcare at the community level, to advocate for and accelerate the provision of information about the efficacy and safety of vaccines, and to expand investments into reducing preventable diseases. Leveraging the full strength and country presence of its partner organisations, the H6 is helping to accelerate progress through initiatives such as the Every Woman Every Child movement to support primary healthcare in countries that are lagging behind. This will be done by ensuring that UHC packages include comprehensive and integrated services for women, children, and adolescents through policy dialogue at regional and country level, supporting community level involvement, and taking multisectoral approaches. Finally, coordinated action to improve quality of care is being tested in 10 priority countries.8

Many coordinated processes have already been put in place to improve measurement. Expert groups have been set up in maternal and newborn health,9 child health, and adolescent health10 to improve harmonisation of measurement and provide coordinated guidance and tools to countries to strengthen capacities in monitoring. In particular, tools and training for subnational and facility level analysis of routine reproductive, maternal, newborn, and child health data using health management information systems are now available and being used.11 Other activities to improve measurement of quality of care and effective coverage include the development of core quality of care indicators for maternal, newborn, and child health and setting up mechanisms to collect and analyse and use those data at subnational and facility level.

The articles in this collection provide some hopeful clues to where future efforts should be focused. For example, although progress has been uneven, the fastest improvements in coverage for sexual and reproductive health, maternal and newborn health, and child and adolescent health have been among the poorest populations. This shows that it is possible to reach the most vulnerable and make a substantial impact. Rights based approaches would further accelerate progress.

However, just as with the millennium development goals, progress has been uneven when you look at income inequality, rural-urban divides, and marginalised and vulnerable populations, including millions of adolescent girls, individuals with disabilities, forcibly displaced people, and children and young people disadvantaged by poverty, exclusion, and lack of available healthcare services in their communities.

These findings should serve as a wake-up call to the global health community. If we do not act to address these issues we will fall short of our commitment to reach the most vulnerable populations with effective, sustainable solutions by 2030. The struggle for health is a struggle against inequality, a struggle against a world in which people die or face serious health consequences as a result of not being able to access health services simply because they are poor or from marginalised groups. We must act together, learn from the mistakes of the past, and coordinate our efforts and resources if we are to achieve health for all.

Tedros Adhanom Ghebreyesus, director general, World Health Organization, Geneva, Switzerland

Henrietta Fore, executive director, United Nations Children’s Fund, New York, USA

Natalia Kanem, executive director, United Nations Population Fund, New York, USA

Winnie Byanyima, executive director, Joint United Nations Programme on HIV and AIDS, Geneva, Switzerland

Phumzile Mlambo-Ngcuka, executive director, UN Women, New York, USA

Annette Dixon, vice president for human development, World Bank, Washington, DC, USA

This article was drafted with the help of Theresa Diaz and Anshu Banerjee from the World Health Organization, Jennifer Requejo from Unicef, and Jean Pierre Monet from United Nations Population Fund.

1 United Nations. The millennium development goals report 2015. 2015. un.org/millenniumgoals/2015_MDG_Report/pdf/MDG%202015%20rev%20(July%201).pdf

2 United Nations General Assembly. Transforming our world: the 2030 agenda for sustainable development. UN,  2015.

3 United Nations Inter-agency Group for Child Mortality Estimation. Levels and trends in child mortality: report 2019. 2019. https://www.unicef.org/reports/levels-and-trends-child-mortality-report-2019

4 World Health Organization. Trends in maternal mortality 2000 to 2017: estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division. WHO, 2019.

5 WHO. Primary health care on the road to universal health coverage. 2019 monitoring report. 2019. https://www.who.int/healthinfo/universal_health_coverage/report/uhc_report_2019.pdf?ua=1

6 WHO. Stronger collaboration, better health: global action plan for healthy lives and wellbeing for all. World Health Organization, 2019.

7 UNFPA. H6 Partnership. https://www.unfpa.org/h6

8 WHO. Quality, equity, dignity: the network to improve quality of care for maternal, newborn and child health—strategic objectives. World Health Organization, 2018.

9 Moran AC, Moller AB, Chou D, et al. “What gets measured gets managed”: revisiting the indicators for maternal and newborn health programmes. Reprod Health 2018;15:19. doi:10.1186/s12978-018-0465-z

10 Guthold R, Moller AB, Azzopardi P, et al. The global action for measurement of adolescent health (GAMA) initiative—rethinking adolescent metrics. J Adolesc Health 2019;64:697-9. doi:10.1016/j.jadohealth.2019.03.008

11 World Health Organization, Unicef. Analysis and use of health facility data. Guidance for RMNCAH program managers, working document, October 2019. https://www.who.int/healthinfo/FacilityAnalysisGuidance_RMNCAH.pdf?ua=1