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January 2020
A series proposed by the Countdown to 2030 for Women’s, Children’s and Adolescents’ Health and PMNCH hosted by the WHO
BMJ Global Health
Leaving no woman, no child,
and no adolescent behind
LEAVING NO ONE BEHIND
1 Reaching all women, children, and adolescents with essential health
interventions by 2030
Ties Boerma, Cesar G Victora, Miriam Lewis Sabin, Paul J Simpson
3 Unless we act now, the most vulnerable will continue to suffer the worst
consequences of violence and abuse of power
Helen Clark
January2020 5 Assessing coverage of interventions for reproductive, maternal, newborn,
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19 Structural determinants of gender inequality: why they matter for
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LEAVING NO ONE BEHIND
56 Intimate partner violence in 46 low-income and middle-income countries:
an appraisal of the most vulnerable groups of women using national
health surveys
Carolina V N Coll, Fernanda Ewerling, Claudia García-Moreno, Franciele Hellwig,
Aluisio J D Barros
65 Women, children and adolescents in conflict countries: an assessment of
inequalities in intervention coverage and survival
Nadia Akseer, James Wright, Hana Tasic, Karl Everett, Elaine Scudder, Ribka Amsalu,
Ties Boerma, Eran Bendavid, Mahdis Kamali, Aluisio J D Barros,
Inácio Crochemore Mohnsam da Silva, Zulfiqar Ahmed Bhutta
75 Wake-up call: 10 years remaining to address inequalities on right to health for all
Tedros Adhanom Ghebreyesus, Henrietta Fore, Natalia Kanem, Winnie Byanyima,
Phumzile Mlambo-Ngcuka, Annette Dixon
77 Advancing women’s, children’s, and adolescents’ health and equity
Nicholas K Alipui, Elizabeth Mason, on behalf of the UN Secretary-General’s Independent
Accountability Panel for Every Woman, Every Child, Every Adolescent
These articles are part of a series proposed by the Partnership for Maternal, Newborn and Child Health (PMNCH) hosted by the World Health
Organization and commissioned by The BMJ, which peer reviewed, edited, and made the decisions to publish. Article handling fees (including
printing, distribution, and open access) are funded by the Bill and Melinda Gates Foundaton and PMNCH.
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EDITORIAL
Reaching all women, children, and adolescents
with essential health interventions by 2030
A marathon that requires a concerted effort
I
f the sustainable development goals BMJ and BMJ Global Health are launching this requires major investments to improve
(SDGs) were a marathon we’d be a new collection of articles that explores the the quality, analysis, and use of such data.
approaching the 14 km mark after data on health inequalities in an attempt to We should also acknowledge that not
a slow start. There would be more answer this question, one third of the way everything can be quantified and a more
than 28 km still to go, and everyone into the marathon (www.bmj.com/leaving- comprehensive understanding of drivers of
has to finish the race. We’re entering the no-one-behind). inequality, including gender bias, is needed
final 10 years of the SDGs. Some runners The collection’s articles are written by through qualitative methods.6
are already falling behind and are at risk of Countdown to 2030 for Women’s, Chil Thirdly, the SDGs and EWEC strategy take
not making the 2030 finishing line. dren’s, and Adolescents’ Health, a global a comprehensive approach that goes beyond
collaboration of academics, the World health service provision by including
Race is on Health Organization, Unicef, and civil nutrition, violence, early childhood
The precursors to the SDGs, the millennium society, with support from the Partnership development, and adolescent health and
development goals, created an impetus that for Maternal, Newborn and Child Health wellbeing. Tackling these challenges
led to unprecedented progress in maternal (PMNCH). Three lessons stand out from requires multisectoral approaches. 7
and child health.1 Even though reducing the collection, which focuses on the Monitoring such a wide array of priority
inequalities was not explicit in the goals’ coverage of essential health interventions areas—60 indicators in the EWEC strategy—
2015 targets, disadvantaged populations for reproductive, maternal, newborn, child, is daunting for all countries and even more
often made faster progress than more privi- and adolescent health and nutrition, such so for low income and lower to middle
leged populations in the goals of improved as skilled birth attendance, vaccinations, income countries with limited analytical
maternal and child survival and coverage of case management of childhood illnesses, capacity.
health interventions mainly because they improved water supply, and insecticide
started from a very low baseline.2 3 treated bed nets to prevent malaria. Completing the marathon
The progress made should be applauded, Firstly, progress is being made in A large gap exists between the language of
but the millennium development goals improving coverage of interventions. the SDGs and monitoring practices used
were a marathon that many participants However, gains tend to slow when national both globally and by countries. A recent
could not complete. Most of the 2015 coverage levels get to around 80%, meeting with 10 countries in sub-Saharan
targets were not met, and poor-rich and revealing the extra effort needed to reach Africa on evidence and practices related to
other inequities remained large. the most vulnerable people. Furthermore, monitoring equity for women’s, children’s,
The SDGs’ mantra, which all countries poor quality of care is a major factor limiting and adolescents’ health found that country
signed up to through the United Nations, the impact of health services. Many women, health plans embraced equity oriented poli-
is “Leave no one behind.” The 2030 goals children, and adolescents continue to live in cies towards universal coverage of essen-
target health and wellbeing for all and the dire circumstances, where they are exposed tial services.8 However, although several
UN’s Every Woman Every Child (EWEC) to armed conflict and bear the consequences countries had explicit plans to disaggregate
global strategy for women’s, children’s, of the violence and collapse of health indicators for monitoring progress, system-
and adolescents’ health (2016-2030) is services, water supply, and food security. atic monitoring and use of equity data was
the unifying roadmap to achieve that for Secondly, we need better data to know generally weak.
women, children, and adolescents.4 who is being left behind. Tracking progress Leaving no woman, no child, no adoles
Both the SDGs and the EWEC global on SDG indicators currently relies largely cent behind is a noble goal and an immense
strategy emphasise equity and recognise on national population surveys with data challenge. Disaggregated data, reliable
that collecting disaggregated data is the on household wealth, education, urban transparent statistics, and evidence on
only way of tracking progress and holding or rural residence, and provinces. These health inequalities form the foundation
governments to account. The need for such data are critical but not enough. Larger for planning, programme implementation,
data is so important that it became a target sample sizes in national surveys and tracking progress, and accountability. We’re
in its own right, with SDG target 17.18 advancing analysis can tell us more about already a third of the way through the SDG
calling for data disaggregated by income, urban poor people, the poorest of the poor, race; we must now identify who is being
gender, age, race, ethnicity, and other subnational populations in districts, or left behind so that we can help everyone
important factors. ethnic minorities.5 Special surveys are also complete the marathon by 2030.
needed for disadvantaged populations such
Competing interests:We have read and understood BMJ
What progress has been made? as migrants and people at high risk of HIV.
policy on declaration of interests and have no interests
Is the focus on leaving no woman, no child, Routine health facility data are a poorly to declare.
and no adolescent behind just rhetoric, or tapped source of information to track local Provenance and peer review: Commissioned; not
is it leading to measurable change? The progress and target interventions. However, externally peer reviewed.
the bmj | BMJ 2020;368:l6986 | doi: 10.1136/bmj.l6986 1
LEAVING NO ONE BEHIND
This article is part of a series proposed by the This is an Open Access article distributed under Estimating global inequalities in reproductive,
Countdown to 2030 for Women’s, Children’s the terms of the Creative Commons Attribution IGO maternal, newborn, and child health. BMJ
and Adolescents’ Health and the Partnership for License (https://creativecommons.org/licenses/ Global Health 2020;5: e002229. doi:10.1136/
Maternal, Newborn and Child Health (PMNCH) by-nc/3.0/igo/), which permits use, distribution, and bmjgh-2019-002229
hosted by the World Health Organization and reproduction for non-commercial purposes in any 6 George A, Amin A, Marques de Abreu Lopes C, et
commissioned by The BMJ, which peer reviewed, medium, provided the original work is properly cited. al. Structural determinants of gender inequality:
edited, and made the decisions to publish. Open why they matter for adolescent girls’ sexual and
access fees are funded by the Bill and Melinda Gates reproductive health. BMJ 2020;368:l6985.
Foundation and PMNCH. doi:10.1136/bmj.l6985
Ties Boerma, professor1,2 7 Kuruvilla S, Hinton R, Boerma T, et al, PMNCH
1 Victora CG, Wagstaff A, Schellenberg JA, Gwatkin D, Multisectoral Collaboration Study Group. Business
Cesar G Victora, emeritus professor3 Claeson M, Habicht JP. Applying an equity lens to not as usual: how multisectoral collaboration can
Miriam Lewis Sabin, technical officer4 child health and mortality: more of the same is not promote transformative change for health and
enough. Lancet 2003;362:233-41. doi:10.1016/ sustainable development. BMJ 2018;363:k4771.
Paul J Simpson, international editor5 S0140-6736(03)13917-7
1 doi:10.1136/bmj.k4771
University of Manitoba, Winnipeg, Canada 2 Victora CG, Requejo JH, Barros AJ, et al. Countdown 8 Countdown to 2030 for Women’s, Children’s and
2
Countdown to 2030 for Women’s, Children’s and to 2015: a decade of tracking progress for maternal, Adolescents’ Health, African Population and Health
Adolescents’ Health newborn, and child survival. Lancet 2016;387:2049- Research Centre. Regional workshop on reducing
3 59. doi:10.1016/S0140-6736(15)00519-X inequalities in reproductive, maternal, newborn
International Centre for Equity in Health, Federal 3 Countdown to 2030 Collaboration. Countdown to
University of Pelotas, Brazil and child health in sub-Saharan Africa: use of
2030: tracking progress towards universal coverage data and evidence for action and accountability,
4
Partnership for Maternal, Newborn, and Child Health, for reproductive, maternal, newborn, and child 10-11 September 2019, Nairobi, Kenya. http://
Geneva, Switzerland health. Lancet 2018;391:1538-48. doi:10.1016/ countdown2030.org/eastern-and-southern-africa/
5
The BMJ, London, UK S0140-6736(18)30104-1 workshop-on-reducing-inequalities-in-rmnch-in-sub-
4 Every Woman Every Child. The global strategy saharan-africa-use-of-data-and-evidence-for-action-
Correspondence to: T Boerma
for women’s, children’s and adolescents’ health. and-accountability
Ties.Boerma@umanitoba.ca
(2016-2030). https://www.globalstrategy.
everywomaneverychild.org
5 Barros AJD, Wehrmeister FC, Ferreira LZ, et Cite this as: BMJ 2020;368:l6986
al. Are the poorest poor being left behind? http://dx.doi.org/10.1136/bmj.l6986
2 doi: 10.1136/bmj.l6986 | BMJ 2020;368:l6986 | the bmj
OPINION
Unless we act now, the most vulnerable will continue
to suffer the worst consequences of violence and
abuse of power
Intimate partner violence and warfare contribute to the inequities experienced by women, children,
and adolescents says Helen Clark
A
s we enter the last decade of women reporting physical or sexual vio- Acting together
the sustainable development lence from intimate partners. Examples in The lessons from both studies are clear.
goals, a new series of analyses other conflict settings in other regions also Unless we ameliorate the abuse of power
tells us whether the world is point to substantial suffering by women: and the exercise of violence, whether car-
on track to reach global tar- 33.2% of women in Colombia and 37.2% ried out in the home or perpetrated on a
gets for health. Two articles, focused on in the Democratic Republic of the Congo country’s citizens by war or civil conflict,
intimate partner violence and the impact faced physical or sexual partner violence. the most vulnerable—the poorest women,
of war, stand out.1 2 They remind us that it These findings underline the need children, and adolescents— will always suf-
is the most vulnerable women, children, to reframe the narrative in the societal fer the worst consequences.
and adolescents who suffer the worst con- discourse on gender in order to tackle Through the alignment efforts of the
sequences of conflict, violence, and the persistent inequalities that are holding Partnership for Maternal, Newborn and
abuse of power. If the global community many women and girls back from achieving Child Health, this BMJ supplement is the
fails to address the inequities affecting the their potential. Gender based violence is first time that key international actors have
most vulnerable populations, they will per- often perceived as being perpetrated by come together to report on progress since the
sist and the global health targets will not men who are strangers to women. However, updated United Nations secretary general’s
be met. much of the violence takes place in domestic Every Woman Every Child Global Strategy for
The new findings are part a series settings by men who are well known to those Women’s, Children’s and Adolescent’s Health
produced by Countdown to 2030 and the affected. (2016-2030).4 Accountability is stronger
Partnership for Maternal Newborn and According to data released in 2018 by when partners improve alignment and
Childhood Health (PMNCH) and published the United Nations Office on Drugs and focus as one on what matters: those being
in The BMJ and BMJ Global Health (www. Crime, 137 women across the world are left behind.
bmj.com/leaving-no-one-behind). The killed by a partner or family member every The articles in this series reach across the
articles shine a light on what needs to be day—and in four of six regions, the home six focus areas of the secretary general’s
done over the next decade to meet 2030 is the most likely place for a woman to be Every Woman Every Child global strategy:
health goals for all. Everyone—from civil killed.3 More than half of the 87 000 women early childhood development; humanitarian
society, grassroots activists, and health killed in 2017 were reported to have died and fragile settings; sexual reproductive
professionals to donors and governments— at the hands of those closest to them. Some health and rights; adolescent health and
has their own critical role as we work 30 000 were killed by an intimate partner. wellbeing; quality, equity, and dignity; and
towards a world where no woman, no child, In developing policy and programmes, women’s empowerment. Importantly, they
and no adolescent is left behind. Increasing we need to acknowledge these facts and use the granular data that are increasingly
effort to reach neglected populations and create interventions that are appropriate becoming available to closely examine the
better scrutiny and accountability are in these scenarios. We also need to involve crucial problem of inequity, both between
needed to ensure that this is done. beneficiaries themselves far more in and within countries.
designing them. It takes political will and resources to
Effects of violence The collection also includes a study make sure that the most vulnerable aren’t
The analysis of intimate partner violence on inequalities in intervention coverage left behind. We must invest even more in
by Coll and colleagues 1 focuses on 46 and survival for women, children, and understanding who is being left behind,
countries and finds wide inequalities for adolescents living in conflict countries.2 where they are, and what life saving health
women aged 15-49, who tend to be poorer Conflict countries have had consistently interventions they are missing. These
and less empowered than other women. higher maternal and child mortality are usually the most expensive groups
These women are especially vulnerable estimates since 1990, and these gaps to reach and often include stigmatised
to psychological, physical, and sexual persist despite rates continually declining communities. Yet, if we are to reach the
violence by their intimate partners. Rates for both groups. Access to essential 2030 health goals, we can no longer afford
tend to be particularly high in conflict reproductive and maternal health services to disregard them.
affected and fragile states. Afghanistan, and child vaccinations for poorer, less
Helen Clark was prime minister of New Zealand
which has been riven by conflict for dec- educated, and rural families are severalfold
from 1999 to 2008. In April 2009 she became the
ades and is a strongly patriarchal society, worse in conflict versus non-conflict first female administrator of the UN Development
has the highest prevalence, with 46.2% of countries. Programme, serving two terms.
the bmj | BMJ 2020;368:l7023 | doi: 10.1136/bmj.l7023 3
LEAVING NO ONE BEHIND
Competing interests: I have read and understood women using national health surveys.BMJ
BMJ policy on declaration of interests and have no Glob Health 2020;5:e002208. doi:10.1136/
relevant interests to declare. bmjgh-2019-002208
2 Akseer N, Wright J, Tasic N, et al. Women, children
Provenance and peer review: Commissioned; not This is an Open Access article distributed under
and adolescents in conflict countries: an assessment
externally peer reviewed. the terms of the Creative Commons Attribution IGO
of inequalities in intervention coverage and survival.
License (https://creativecommons.org/licenses/
This article is part of a series proposed by Countdown BMJ Glob Health 2020;5:e002214. doi:10.1136/
by-nc/3.0/igo/), which permits use, distribution,
to 2030 for Women’s, Children’s and Adolescents’ bmjgh-2019-002214
and reproduction for non-commercial purposes in
Health and the Partnership for Maternal, Newborn 3 UN Office on Drugs and Crime. Global study on
any medium, provided the original work is properly
and Child Health (PMNCH) hosted by the World Health homicide. 2018. unodc.org/documents/data-and-
cited.
Organization and commissioned by The BMJ, which analysis/GSH2018/GSH18_Gender-related_killing_
peer reviewed, edited, and made the decisions to of_women_and_girls.pdf
publish these articles. Article handling fees are funded 4 Every Woman Every Child. Global strategy for
by the Bill and Melinda Gates Foundation and PMNCH. women’s, children’s and adolescent’s health (2016-
2030). http://www.everywomaneverychild.org/
Helen Clark, PMNCH board chair
1 Coll CVN, Ewerling F, Garcia-Moreno C, Hellwig F, global-strategy/
Partnership for Maternal, Newborn and Child Health Barros AJD. Intimate partner violence inequalities
Board, Geneva, Switzerland in 46 low and middle-income countries: an Cite this as: BMJ 2019;368:l7023
Correspondence to: pmnchboardchair@who.int appraisal of the most vulnerable groups of http://dx.doi.org/10.1136/bmj.l7023
4 doi: 10.1136/bmj.l7023 | BMJ 2020;368:l7023 | the bmj
ANALYSIS
Assessing coverage of interventions for
reproductive, maternal, newborn, child, and
adolescent health and nutrition
Progress has been made in priority interventions, but we need new measurement systems
that include the whole life course and give better assessment of equity of coverage, argue
Jennifer Requejo and colleagues
E
mbedded within the framework than others but with pervasive inequities supplies and equipment, and healthcare
of the United Nations sustain- between and within countries.4 workers. The framework also considers
able development goals (SDG) The Countdown to 2030 initiative contextual factors, such as humanitarian
for 2030 is the principle of also regularly tracks progress in the and environmental crises, women’s social
equity, with the aim of reach- countries experiencing the highest status, and other political and economic
ing universal health coverage. Soon after burdens of maternal and child mortality. factors that influence access to services,
the framework was adopted in 2015, the Countdown’s 2017 report,5 together with and the independent effects of education
Every Woman Every Child global strategy those from Every Woman Every Child, and other life opportunities on health.
for women’s, children’s and adolescents’ highlight laudable reductions in maternal
health was launched.1 2 The global strat- and child mortality over the past two Understanding gaps and success
egy translates the SDG agenda into concrete decades, but many settings will need to Multiple analytical lenses are needed to
guidance on how to accelerate progress increase efforts to achieve the 2030 goals. understand whether women, children,
in women’s, children’s and adolescents’ Coverage of essential health interventions and adolescents worldwide are receiving
health through a multisectoral approach. is unacceptably low in many contexts and effective health interventions. Snapshots
It includes a monitoring framework with among specific populations; considerable of current status tell us where we are and
60 indicators to help countries and their policy and programmatic work is needed how far we need to go to reach global goals.
partners promote accountability in end- to shore up primary healthcare systems to However, it’s important to visualise trends
ing preventable deaths (survive), ensur- make universal health coverage a reality.5 to determine whether progress is accelerat-
ing health and wellbeing (thrive), and We combine the countdown and global ing, stagnating, or even reversing. Count-
strategy indicators to take stock of progress down’s indicator list helps determine which
expanding enabling environments, so that
in all 138 low and middle income countries specific interventions are reaching women,
all women, children, and adolescents can
plus Panama, which was reclassified children, and adolescents better than oth-
reach their potential (transform).3 Previous
as a high income country in 2018 but ers. Another approach involves ranking
assessments show mixed progress, with
remains a priority country in Countdown countries and regions to identify those that
some indicators advancing more rapidly
to 2030.6 We examine how well the world are performing best and those that are lag-
is doing in reaching every woman, child, ging behind, providing insight into which
KEY MESSAGES and adolescent with effective health countries and regions need constructive
interventions, how far we need to go to action to direct resources and support.
• Despite substantial progress in reduc-
achieve the SDGs, and identify gaps in
ing maternal, newborn, and child
mortality worldwide, inequities persist the data. We also propose revisions to Where are we now?
the Countdown chart of key indicators Countdown’s continuum of care chart
• Countries in sub-Saharan Africa are so that it better reflects the dimensions shows a subset of prioritised indicators of
lagging most behind
of survive, thrive, and transform in intervention coverage across the dimen-
• Coverage of interventions is higher for the Every Woman Every Child strategy sions of family planning, pregnancy, child-
those that are well resourced, can take
and the interconnecting links between birth, postnatal care, and childhood, with
place at planned times (such as pre-
reproductive, maternal, newborn, child, selected crosscutting indicators for water
ventive services), and do not depend
and adolescent health and nutrition. and sanitation. These indicators reflect
on a functioning healthcare system
Our assessment is based on the common population level data, showing how well
• The indicators for monitoring pro- evaluation framework underlying the countries are doing in reaching those in
gress need to be revised to include
countdown and global strategy analyses need. Figure 1 shows progress on this chart
proved interventions for older chil-
(see web supplement). This framework for all low and middle income countries for
dren, adolescents, and adult women
posits that health outcomes are determined 2014-18.7 8 Summary data (table 1) show
• Further disaggregation of interven- by the ability of healthcare systems to that we are far from achieving universal
tion coverage by equity measures is deliver high quality services to all, which, coverage for many interventions, with
important to better understand who
in turn, depends on supportive policies and larger gaps for family planning services,
is being left behind
sufficient resources, including financial, breastfeeding, and treatment of childhood
the bmj | BMJ 2020;368:l6915 | doi: 10.1136/bmj.l6915 5
LEAVING NO ONE BEHIND
100
Coverage estimate (%)
80
60
40
20
0
Demand for family
planning satisfied with
modern methods
Antenatal care (4+ visits)
Treatment of
pregnant women
with HIV
Neonatal tetanus
protection
Skilled attendant
at delivery
Postnatal visit
for mothers
Postnatal visit
for babies
Early initiation
of breastfeeding
Exclusive breastfeeding
(LEAVING NO ONE BEHIND
Table 1 | Coverage of priority indicators for women’s and children’s health in low and middle income countries* 2014-187
No of Coverage
countries Median (interquartile Minimum Maximum Countries with
Indicator with data range) coverage (%) (%) (%) lowest value Countries with highest value
Pre-pregnancy
Demand for family 77 56 (42-74) 5 90 Albania North Korea
planning satisfied with
modern methods
Pregnancy
Antenatal care (4+ visits) 74 73 (53-89) 18 98 Afghanistan Cuba
Treatment of pregnant 93 79 (46-93) 5 99 Sudan Benin, Bolivia, Cuba, Grenada, Jamaica, Mozambique,
women living with HIV Mauritius, Malawi, Malaysia, Namibia, Romania, Rwanda,
Sao Tome and Principe, Suriname, Saint Vincent and the
Grenadines, Zambia
Neonatal tetanus 99 90 (85-94) 60 99 Central African Dominican Republic, Eritrea, Guyana, Honduras, Sri Lanka,
protection Republic, Nigeria Maldives, Sao Tome and Principe
Birth
Skilled attendant 109 92 (74-99) 20 100 Chad Turkmenistan, Uzbekistan
at delivery
Postnatal
Postnatal visit 68 71 (50-90) 1 100 Colombia Turkmenistan
for mothers
Postnatal visit for babies 61 64 (32-91) 4 100 Chad Turkmenistan
Early initiation of 68 54 (41-67) 20 90 Pakistan Sri Lanka
breastfeeding
Infancy
Exclusive breastfeeding 68 46 (35-58) 0 87 Chad Rwanda
(LEAVING NO ONE BEHIND
Table 2 | Changes in median national coverage of selected interventions in low and middle income countries with available data for 2009-13 and
2014-18, ordered by proportion of the gap closed
No of 2009-13 2014-18 Change
Stage Indicator countries median median (% points) % of gap closed
Pregnancy Treatment of pregnant women with HIV 93 10 79 69 77
Infancy Rotavirus immunisation 34 69 87 18 58
Postnatal Postnatal visit for babies 31 30 68 38 54
Pregnancy Neonatal tetanus protection 99 85 90 5 33
Pregnancy ≥4 antenatal contacts 63 60 73 13 32
Birth Skilled attendant delivery 95 90 93 3 30
Postnatal Postnatal visit for mothers 38 44 59 15 27
Environment Population using basic drinking water services 138 88 91 3 25
Infancy Exclusive breastfeeding (LEAVING NO ONE BEHIND
Cuba 89 100 98 99 99 99 61 93 89 99 99 77 91 80-100%
North Korea 90 100 94 97 98 96 74 86 90 97 97 80 91 60-79%
Thailand 89 99 91 97 96 99 72 80 89 95 97 76 89 40-59%
Kazakhstan 79 99 95 98 99 95 62 81 79 97 98 72 86 20-39%
Belarus 74 100 100 97 97 98 45 93 74 100 97 69 85 0-19%
Equatorial Guinea 21 68 67 25 30 63 40 54 21 68 36 47 43
Yemen 38 45 25 65 64 64 25 34 38 35 64 30 42
Central African Republic 29 40 38 47 49 74 16 30 29 35 54 23 36
South Sudan 6 19 17 49 51 52 39 48 6 18 50 43 29
Chad 20 20 31 41 37 59 20 26 20 26 44 23 28
Demand for family
planning satisfied with
modern methods
Skilled attendant
at delivery
Antenatal care (4+ visits)
DTP3 immunisation
Measles immunisation
(first dose)
BCG immunisation
Diarrhoea: oral
rehydration treatment
Careseeking for
pneumonia symptoms
Component 1:
Family planning
Component 2:
Maternity care
Component 3:
Child immunisation
Component 4:
Case mangement
CCI score
Fig 3 | Heatmap of the composite coverage index (CCI) for the five best and worst performing low and middle income countries with available
data, 2010-18, showing values for constituent indicators and four components of the index
small so that reporting burdens on countries readiness to provide high quality care and non-comparable data, limiting inclusion
are manageable yet comprehensive enough health workers’ performance.19 in global databases. Conflict or other
to be relevant and spur action. We cannot The importance of a life course approach circumstances can also preclude nationally
lose sight of the fact that the leading killers has become internationally recognised, representative household surveys, and
of young children stubbornly remain as has the salience of viewing women’s, some countries have not provided the
pneumonia, diarrhoea, and malaria (in children’s, and adolescents’ health as resources to carry out surveys.
endemic areas), often underpinned by interlinked and having intergenerational Global stewardship is now needed on
undernutrition. But the indicator set effects. However, data collection efforts several fronts:
needs to encompass children aged 5-9 are a few steps behind, with data gaps
• To increase data collection efforts and to
years, along with other emerging priorities and measurement challenges persisting.
generate more comparable data
relating to chronic diseases, disabilities, Even for those indicators that cover well
• To increase investments in countries’
injuries, violence, and child development. established interventions, many countries
health information systems and promote
Adolescent health has garnered are missing data from the past five years
better use of existing data
considerable attention in recent years.15 (tables 1 and 2). Most of the 139 countries
• To coordinate existing initiatives on
However, only a few adolescent specific have modelled data for established
updating core lists of indicators to moni-
indicators have been included in global interventions such as immunisations,
tor progress towards the 2030 goals
monitoring frameworks, mainly around water and sanitation, and HIV. The number
• To refine and move forward the measure-
reproductive and maternal health, and of countries with household survey based
ment agenda, and
most are not included as part of routine data range from 61 (for postnatal care for
• To push for accountability so that every
data collection activities, which hampers babies) to 109 (for skilled attendant at
woman, child, and adolescent gets the
accountability.16 birth). This wide range in data availability
care they deserve.
In response to evidence documenting an is due to a combination of factors—some
increasing proportion of child deaths in of the interventions are new or have never Promising efforts are under way to
the neonatal period, numerous initiatives been included in country programmes or close data gaps for women, children, and
have aimed to improve monitoring data collection processes (eg, rotavirus adolescents.16 20 WHO and Unicef have
around maternal and newborn health, vaccine, postnatal care for babies) but engaged experts to reach consensus on how
including health systems, community, many of the 139 countries have not to define and measure effective coverage in
and broader social, political, and conducted a household survey in the past order to better capture the potential effect
environmental determinants, and the five years. As countries develop and move health services can have on health and
design and implementation of effective from low income to middle income status, nutrition outcomes.21 Many of the indicators
programmes.17 18 This has also prompted they often decide to carry out their own included in global monitoring frameworks
greater focus on the quality of care provided national household surveys, which do not and in the continuum of care chart (fig 1)
before, during, and immediately after always follow standardised methods (such capture information on service contacts
delivery and motivated the development as the international demographic and and do not provide information on quality
of guidance on assessing health facility health surveys). These surveys generate of care, which is desperately needed.
the bmj | BMJ 2020;368:l6915 | doi: 10.1136/bmj.l6915 9LEAVING NO ONE BEHIND
A consultative process for revising the Finally, further disaggregation of
continuum of care chart should incorporate intervention coverage by key markers
all these changes on the global landscape, of equity and the application of newer
This is an Open Access article distributed under
technical advancements in measurement, techniques such as geospatial analyses are the terms of the Creative Commons Attribution IGO
and country realities. Both the Countdown essential to improve our understanding of License (https://creativecommons.org/licenses/
and Every Woman Every Child indicator who is being left behind. This information by-nc/3.0/igo/), which permits use, distribution, and
reproduction for non-commercial purposes in any
lists were derived from lengthy consultative is the starting point for designing strategies
medium, provided the original work is properly cited.
processes involving academia, civil society, to reach all women and children, and
UN agencies, healthcare professionals, and for holding all to account for successful
countries’ ministries of health.3 5 A similar implementation.
process, soon to be instituted, will allow 1 United Nations General Assembly. Transforming
Competing interests: We have read and understood
reporting on key indicators of intervention BMJ policy on declaration of interests and have no our world: the 2030 agenda for sustainable
coverage at the midpoint of the SDG period, relevant interests to declare. The authors alone are development. New York, 2015.
responsible for the views expressed in this article, 2 Every Woman Every Child, Executive Office of the
enabling assessment of whether global United Nations Secretary-General. Global Strategy for
which does not necessarily represent the views,
progress is on track. This consultative decisions, or policies of the institutions with which Women’s, Children’s and Adolescents’ Health (2016-
process should be informed by the ongoing the authors are affiliated. Funding from USAID and 2030). New York, 2015.
DFID was used to help support some analysis, graphic 3 Every Woman Every Child, Executive Office of the
work of relevant global accountability and United Nations Secretary-General. Indicator and
design, and to organise references.
monitoring initiatives.22-24 The process monitoring framework for the global strategy for
should examine how best to obtain data for Contributors and sources: JR, TD, DC, DJ, ABM, RG, women’s, children’s and adolescents’ health (2016-
KS conceived the outline of this paper and drafted 2030). New York, 2016.
missing or under-represented areas such as
the first version, LP and AC conducted analysis of 4 World Health Organization, Joint United Nations
children aged 5-9, adolescents aged 10-14, data to create the CoC and CCI. DC, DJ, ABM, RG, KS, Programme on HIV/AIDS, United Nations Population
adolescent indicators beyond reproductive ACM, LS, JPM, and AB reviewed and revised drafts Fund, United Nations Children’s Fund, UN Women,
and maternal health, environmental of the manuscript, and JR and TD created the final World Bank Group. Survive, thrive, transform. Global
version. The data used for the analyses come from strategy for women’s, children’s and adolescents’
indicators beyond water and sanitation, publicly available Unicef and WHO global databases, health: 2018 report on progress towards 2030
and a wider list of reproductive and much of which comes from the Demographic and targets. WHO, 2018.
sexual health indicators as part of health Health Survey (https://dhsprogram.com) and Multiple 5 Countdown to 2030 Collaboration. Countdown to
Indicator Cluster Survey (https://mics.unicef.org/) 2030: tracking progress towards universal coverage
outcomes for adult women. for reproductive, maternal, newborn, and child
programmes.
The revised chart should still be health. Lancet 2018;391:1538-48. doi:10.1016/
viewed as embedded within the common Data availability: Data are available from the authors S0140-6736(18)30104-1
evaluation framework, serving as a starting on reasonable request, including the underlying data 6 World Bank. Classifying countries by income. 2018.
files used to generate the figures and the associated http://datatopics.worldbank.org/world-development-
point for further analyses focusing on key code. indicators/stories/the-classification-of-countries-by-
drivers of coverage such as equity, policy income.html
Provenance and peer review: Commissioned; 7 United Nations Children’s Fund. Unicef data. 2019.
and legislative frameworks, and contextual externally peer reviewed. https://data.unicef.org/
and health systems factors. A companion 8 World Health Organization. Global Health
This article is part of a series proposed by Countdown
chart on quality of care measures is also to 2030 for Women’s, Children’s and Adolescents’ Observatory data repository. 2019. https://www.
being developed.25 Unicef and WHO, in Health and the Partnership for Maternal, Newborn who.int/gho/database/en/
and Child Health (PMNCH) hosted by the World Health 9 World Health Organization, United Nations Children’s
partnership with Countdown to 2030, the
Organization and commissioned by The BMJ, which Fund. Progress and challenges with achieving
UN Population Fund (UNFPA), and other peer reviewed, edited, and made the decisions to universal immunization coverage: 2018 WHO/Unicef
UN agencies will lead this consultative publish. Open access fees are funded by the Bill and estimates of national immunization coverage. 2019.
process. Melinda Gates Foundation and PMNCH. 10 Wehrmeister FC, Restrepo-Mendez MC, Franca
GV, Victora CG, Barros AJ. Summary indices for
Jennifer Requejo, senior adviser1
monitoring universal coverage in maternal and child
Conclusion Theresa Diaz, coordinator2 health care. Bull World Health Organ 2016;94:903-
Our analyses show that work is needed to Lois Park, researcher3,4 12. doi:10.2471/BLT.16.173138
11 UN Interagency Group for Child Mortality Estimation.
achieve universal coverage of important Doris Chou, medical officer2
Levels and trends in child mortality: report 2018.
health interventions and to prevent inter- Allysha Choudhury, statistics adviser1 Estimates developed by the UN interagency group for
ventions with high coverage levels, such as Regina Guthold, scientist2 child mortality estimation. New York, 2018.
12 Alkema L, Chou D, Hogan D, et al, UN Maternal
immunisations, from backsliding. Indicator Debra Jackson, professor1,5
Mortality Estimation Inter-Agency Group
lists and reporting processes must evolve so Ann-Beth Moller, technical officer2 collaborators and technical advisory group. Global,
that they remain relevant to guide national Jean-Pierre Monet, technical officer6 regional, and national levels and trends in maternal
action and programmatic responses. We Allisyn C Moran, scientist2 mortality between 1990 and 2015, with scenario-
based projections to 2030: a systematic analysis by
have suggested a consultative process for Lale Say, coordinator2 the UN maternal mortality estimation interagency
revising Countdown’s continuum of care Kathleen L Strong, scientist2 group. Lancet 2016;387:462-74. doi:10.1016/
chart to bring it up to date with new think- Anshu Banerjee, chair2,7 S0140-6736(15)00838-7
13 UN Children’s Fund, WHO, International Bank for
ing on life course approaches and to ensure 1
Unicef, New York, USA Reconstruction and Development, World Bank.
a manageable set of indicators for report- 2
World Health Organization, Geneva, Switzerland Levels and trends in child malnutrition: key findings
ing on the survive, thrive, and transform 3
Johns Hopkins University, Baltimore, USA of the 2019 edition of the joint child malnutrition
dimensions of the Every Woman Every 4 estimates. WHO, 2019.
University of Southern California, Los Angeles, USA
14 World Bank Group. Fragile and conflict affected
Child strategy. We believe greater invest- 5
University of Western Cape, Cape Town, South Africa situations. World Bank, 2019.
ment in data collection is needed so that 6
UNFPA, New York, USA 15 World Health Organization. Global reference list
all countries can report on a core set of indi- 7
United Nations H6+ Technical Group, New York, USA, of health indicators for adolescents (aged 10–19
years). WHO, 2015.
cators, enabling meaningful assessments of Correspondence to: J Requejo 16 Guthold R, Moller AB, Azzopardi P, et al. The global
global progress. jrequejo@unicef.org action for measurement of adolescent health
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(GAMA) initiative-rethinking adolescent metrics. J 21 Amouzou A, Leslie HH, Ram M, et al. Advances in the 25 World Health Organization. Quality of care for
Adolesc Health 2019;64:697-9. doi:10.1016/j. measurement of coverage for RMNCH and nutrition: maternal and newborn health—a monitoring
jadohealth.2019.03.008 from contact to effective coverage. BMJ Glob framework for network countries. WHO, 2019.
17 World Health Organization, United Nations Children’s Health 2019;4(Suppl 4):e001297. doi:10.1136/
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18 Moran AC, Jolivet RR, Chou D, et al. A common Fund, World Bank. Nurturing care for early childhood
monitoring framework for ending preventable development: a framework for helping children
tion on indicator lists for the Every Woman
maternal mortality, 2015-2030: phase I of a survive and thrive to transform health and human Every Child global strategy and Countdown
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2016;16:250. doi:10.1186/s12884-016-1035-4 23 Coll-Seck A, Clark H, Bahl R, Peterson S, Costello A, lying the analyses, the methods used to
19 World Health Organization. Standards for improving Lucas T. Framing an agenda for children thriving in
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indicators. PLoS One 2018;13:e0204763. groups on measurement. https://www.who.int/data/ Cite this as: BMJ 2020;368:l6915
doi:10.1371/journal.pone.0204763 maternal-newborn-child-adolescent http://dx.doi.org/10.1136/bmj.l6915
the bmj | BMJ 2020;368:l6915 | doi: 10.1136/bmj.l6915 11ANALYSIS
How can we realise the full potential of health
systems for nutrition?
Poor nutrition contributes substantially to global disease, diminishing the wellbeing of women and
children in low and middle income countries, and better nutrition must be part of the universal
health coverage agenda, say Rebecca Heidkamp and colleagues
O
ver the past decade, global postnatal care, and for the first two years of early initiation of breastfeeding to be a
efforts to raise awareness life. Additionally, weight gain is monitored proxy for intervention by birth attendants
of malnutrition have been and nutritional supplements, particularly at delivery to support timely breastfeeding.8
accompanied by national iron folic acid, provided during antenatal We characterised zinc for diarrhoea as a
movements to gain high care. Common interventions for young chil- nutrition intervention and oral rehydration
level political commitment and accelerate dren include high dose vitamin A supple- solution as the health service because not
actions, proved to work, to improve nutri- ments, growth monitoring and screening all episodes of diarrhoea require contact
tion.1 Despite this momentum, by 2018 just for, and treatment of, acute malnutrition, with a health provider but all children who
under half of countries are on track to meet and treatment of childhood diarrhoea with receive oral rehydration solution should
at least one of nine nutrition related targets zinc tablets in combination with oral rehy- also receive zinc.
set by the World Health Assembly for 2025 dration solution.5 We also examined coverage equity gaps
(table 1).4 Many countries are not achiev- in two ways. Firstly, we looked at absolute
ing the goals because coverage of effective Are health systems reaching target groups differences in coverage across rural and
interventions remaHealth systems are the with nutrition interventions? urban areas; secondly, we examined
primary vehicle for nutrition interventions Gaps in data on the coverage of nutrition subnational variability in coverage by
in many low and middle income countries. interventions are hampering efforts to comparing the region with highest coverage
Ideally, health systems reach women and evaluate progress, estimate benefits, and with the region with lowest coverage. We
children through frequent antenatal care, advocate further investments. 6 Global examined trends by income group using
normal and emergency delivery services, household survey programmes, including countries that had at least one additional
early postnatal care, and preventive and the demographic and health surveys and survey between 2008 and 2012. Indicator
curative care throughout early childhood. multiple indicator cluster surveys, have his- definitions, detailed methods, a discussion
Nutrition interventions commonly include torically included a limited set of nutrition of limitations, and country data are
counselling about diets and infant and coverage indicators. These national sources available in the web supplement.
young child feeding during antenatal care, enable aggregation and comparison of com- Several findings stand out. Firstly,
mon indicators within and across countries. closing the opportunity gap by increasing
However, such data are available for less nutrition intervention coverage among
KEY MESSAGES than half of the evidence based nutrition those already reached by health services
• Most essential nutrition interventions interventions recommended by the World should be an immediate priority. The
are delivered through health systems Health Organization (table 2). Nevertheless, coverage of most nutrition interventions
we can still use available data to identify falls far below the reach of health services
• Global movements to scale up effec-
tive nutrition interventions and opportunities to influence health systems through which they are delivered,
achieve universal health coverage for nutrition more effectively. particularly for antenatal care and delivery
have not been connected to help each We studied publicly available data for care (fig 1). Closing this gap is essential to
realise their full potential five evidence based nutrition interventions7 reach targets. A recent study from Malawi
and their associated service delivery using national data estimated that if all
• S caling up nutrition interventions
for maternal, newborn, and child care women who reported antenatal care visits
among those who are already reached
for 50 countries that had at least one had received all recommended nutrition
by health services is an important first
Demographic and Health Survey or interventions, including iron folic acid, and
step for accelerating progress
Multiple Indicator Cluster Survey from counselling on appropriate nutrition during
• Other countries can learn from the 2013 to 2018. We pooled countries by pregnancy and optimal breastfeeding, the
experience of those that seem to be
World Bank country income group. We prevalence of low birthweight would have
on track to achieving universal health
characterised the delivery “opportunity had a relative 21% decrease, from 14% to
coverage for specific health services
gap” as the absolute difference between 11%, and early initiation of breastfeeding
and nutrition interventions
coverage of the nutrition intervention and would improve by almost 10 percentage
• We need to deal with the widespread coverage of the health service through points, from 76% to 86% (Joseph et al,
gaps in data on the coverage of nutri- which it is commonly delivered—for unpublished data).
tion interventions if we want to moni- example, iron folic acid supplementation Secondly, children are being left
tor progress and achieve universal is the nutrition intervention delivered behind. The reach of nutrition services
coverage
through antenatal care. We considered targeted at children is falling far behind
12 doi: 10.1136/bmj.l6911 | BMJ 2020;368:l6911 | the bmjLEAVING NO ONE BEHIND
Table 1 | Nutrition related goals in the global nutrition monitoring framework for maternal, is stagnant in urban areas of low income
infant, and young child nutrition2 and the non-communicable diseases global monitoring countries, with slow improvements in
framework3 iron folic acid coverage in rural areas.
Target Goal The opportunity gap is closing rapidly
Nutrition2 in upper middle income countries, but
1 Stunting 40% reduction in the number of children under-5 who are stunted this seems to be because antenatal care
2 Anaemia 50% reduction of anaemia in women of reproductive age coverage is stagnating, particularly among
3 Low birth weight 30% reduction in low birth weight
urban populations, even as iron folic acid
4 Childhood overweight No increase in childhood overweight
5 Breastfeeding Increase the rate of exclusive breastfeeding in the first 6 months up to at least 50%
coverage improves (fig 3).
6 Wasting Reduce and maintain childhood wasting to less than 5% Births in health facilities are increasing
Non-communicable diseases3 and the rural-urban equity gap has narro
4 Salt intake 30% relative reduction in mean population intake of salt/sodium wed, with gains in rural areas. At the same
6 Adult raised blood 25% relative reduction in prevalence of raised blood pressure or contain the time, we observe sharp declines in early
pressure prevalence of raised blood pressure, depending on national circumstances initiation of breastfeeding, particularly
7 Diabetes and obesity No change in the prevalence of adult and adolescent diabetes,
overweight and obesity
among urban populations in low income
countries (fig 4). The reasons for this are
not clear. Increases in caesarean births may
contribute to the decline in early initiation
that for women. For example, zinc for Are we headed in the right direction? of breastfeeding in lower and upper middle
diarrhoea treatment in children had the Coverage of nutrition interventions across income countries but caesarean births
lowest coverage among the interventions country income groups is similar (fig 1). remain low overall in sub-Saharan Africa.10
we examined. Nearly 15 years after the The exception is high dose vitamin A sup- A recent analysis of data from 2005 to 2017
release of the WHO recommendation plementation, which is not universally shows that early initiation of breastfeeding
for zinc to treat diarrhoea and multiple distributed in upper middle income coun- increased only in countries where the
“calls to action” by leading public health tries, presumably owing to lower rates of coverage of institutional births improved by
researchers,9 coverage among children with deficiency. However, progress—defined by at least 20 percentage points.11
diarrhoea is only 16% (fig 1). increasing coverage and decreasing ine- Questions on coverage of breastfeeding
Thirdly, some subpopulations are being quality over time—varies by both interven- counselling during early postnatal care
left behind. Rural coverage generally lags tion and income group. Figures 3-6 show were only added to the demographic and
behind urban coverage but disparities are the variability in progress across country health surveys and multiple indicator
not large. The biggest coverage disparities income groups, comparing changes in rural cluster surveys in 2015, thus precluding
within countries are between subnational and urban coverage of nutrition interven- analyses of trend. Among the few coun
regions (fig 2). This can be seen clearly in tions and their associated health services tries with available data for 2013-18,
Cambodia, where the equity gap between over the past decade. however, we saw that 75% of women
rural and urban areas for iron folic acid The opportunity gap between antenatal received breastfeeding counselling in the
is less than three percentage points but care and iron supplementation during first two days whereas only 60% reported
the equity gap between the provinces pregnancy has reduced in lower middle an early postnatal visit with a health
of Cambodia with highest and lowest income countries; however, the rural- provider. Higher coverage of breastfeeding
iron folic acid coverage is 55 percentage urban equity gap remains. Coverage of counselling may reflect the support
points. both iron folic acid and antenatal care provided before hospital discharge, a
Table 2 | Availability of household survey data (Demographic and Health Survey-7 or Multiple Indicator Cluster Survey-6 core questionnaires) on
WHO recommended nutrition interventions delivered through health systems (adapted from Gillespie et al, BMJ Global Health, 2019)6
Stage Data available Data missing
Pre-pregnancy • Folic acid
• Iron supplements
Antenatal care • Iron-folic acid supplements • Counselling about mother’s diet and use of supplements
• Deworming • Counselling and support for breastfeeding
• Balanced energy protein supplements
• Multiple micronutrient supplements
• Calcium supplements
• Vitamin A supplements
Delivery/early •Support for early initiation of breastfeeding at delivery • Delayed cord clamping
postnatal care •Counselling and support for exclusive breastfeeding • Post partum iron supplementation
(first two days only)
Childhood • Vitamin A • Screening for acute malnutrition
preventive care • Receipt of micronutrient powders •C ounselling and support for exclusive and continued breastfeeding after
the first two days
• Counselling and support for complementary feeding
• Food supplements
•R eceipt of supplements other than micronutrient powders
(iron; multiple micronutrient supplements; preventive zinc)
Childhood •Zinc for diarrhoea (recommended with oral rehydration solution) •C overage of community based management of acute malnutrition
recuperative care •Receipt of ready-to-use therapeutic food (treatment of those with confirmed severe acute malnutrition/moderate
•Receipt of ready-to-use supplementary food acute malnutrition)
the bmj | BMJ 2020;368:l6911 | doi: 10.1136/bmj.l6911 13You can also read
