Survive, Thrive, TranSform - Global Strategy for Women's, Children's and adolescents' health (2016-2030) 2018 monitoring report: current status ...

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Survive, Thrive, TranSform - Global Strategy for Women's, Children's and adolescents' health (2016-2030) 2018 monitoring report: current status ...
Survive, Thrive, Transform
Global Strategy for Women’s, Children’s
and Adolescents’ Health (2016–2030)
2018 monitoring report:
current status and strategic priorities

                             Special theme:
               early childhood development
Survive, Thrive, TranSform - Global Strategy for Women's, Children's and adolescents' health (2016-2030) 2018 monitoring report: current status ...

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Survive, Thrive, TranSform - Global Strategy for Women's, Children's and adolescents' health (2016-2030) 2018 monitoring report: current status ...
Acronyms and abbreviations..........................................iv


10 key MESSAGES from this

Executive summary............................................................viii

Introduction.......................................................................... 1

SPECIAL THEME: early childhood development..........3

Women’s health......................................................................9

Children’s health................................................................ 13

Adolescents’ health.......................................................... 17

UHC, health systems, major diseases and
humanitarian SETTINGS...................................................... 21

Multisectoral action.......................................................27

Equity, Gender, rights and governance................... 31

Data matters .........................................................................35


Annexes.................................................................................... 41
    Annex 1:
    Country support through EWEC and the EWEC ecosystem.......... 42

    Annex 2:
    Regional dashboards on 16 key indicators: current status........ 45


Acknowledgements ..........................................................55
Survive, Thrive, TranSform - Global Strategy for Women's, Children's and adolescents' health (2016-2030) 2018 monitoring report: current status ...
Acronyms and abbreviations
     AA-HA!     Accelerated Action for the Health         IPA        International Pediatric Association
                of Adolescents
                                                          LMICs      Low- and Middle-Income Countries
     AIDS       Acquired Immune Deficiency
                                                          MICS       Multi Indicator Cluster Survey
                                                          MNCH       Maternal, Newborn and Child Health
     ANI        Accelerating Nutrition Improvements
                                                          MoNITOR    Mother and Newborn Information
     CCD        Care for Child Development
                                                                     for Tracking Outcomes and Results
     CRVS       Civil Registration and Vital Statistics
                                                          NCDs       Noncommunicable Diseases
     DALYs      Disability-Adjusted Life Years
                                                          PMNCH      Partnership for Maternal, Newborn &
     DHS        Demographic and Health Survey                        Child Health
     DTP3       Diphtheria-Tetanus-Pertussis Vaccine      RMNCAH     Reproductive, Maternal, Newborn,
                                                                     Child and Adolescent Health
     ECD        Early Childhood Development
                                                          RMNCH      Reproductive, Maternal, Newborn
     ECDI       Early Childhood Development Index
                                                                     and Child Health
     EQUIST     Equitable Impact Sensitive Tool
                                                          SDGs       Sustainable Development Goals
     EWEC       Every Woman Every Child
                                                          STIs       Sexually Transmitted Infections
     FGM        Female Genital Mutilation
                                                          SRHR       Sexual and Reproductive Health
     FIGO       International Federation of                          and Rights
                Gynecology and Obstetrics
                                                          TB         Tuberculosis
     GFF        Global Financing Facility in support
                                                          UHC        Universal Health Coverage
                of Every Woman Every Child
                                                          UN         United Nations
     GLAAS      Global Analysis and Assessment of
                Sanitation and Drinking-Water             UNAIDS     Joint United Nations Programme
                                                                     on HIV/AIDS
     HDC        Health Data Collaborative
                                                          UNESCO     United Nations Organization for
     HEAT       Health Equity Assessment Toolkit
                                                                     Education, Science and Culture
     HIS        Health Information System
                                                          UNFPA      United Nations Population Fund
     HIV        Human Immunodeficiency Virus
                                                          UNGA       United Nations General Assembly
     HLSG       High-Level Steering Group
                                                          UNICEF     United Nations Children’s Fund
     HPV        Human Papillomavirus
                                                          UN Women United Nations Entity for Gender
     IAP        Independent Accountability Panel                   Equality and the Empowerment
                                                                   of Women
     ICM        International Confederation of
                Midwives                                  USAID      United States Agency for
                                                                     International Development
     ICN        International Council of Nurses
                                                          WASH       Water, Sanitation and Hygiene
     INFORM     Global Risk Index
                                                          WGI        Worldwide Governance Indicators
     INSPIRE    Implementation and enforcement
                of laws; Norms and values; Safe           WHO        World Health Organization
                environments; Parent and caregiver
                support; Income and economic
                strengthening; Response and
                support services; and Education
                and life skills

iv   Survive, Thrive, Transform - GS 2018 monitoring report: current status and strategic priorities
Survive, Thrive, TranSform - Global Strategy for Women's, Children's and adolescents' health (2016-2030) 2018 monitoring report: current status ...
At the heart of the Every Woman Every Child
Global Strategy (EWEC Global Strategy) for
Women’s, Children’s and Adolescents’
Health is a simple and profound idea: if
every person could unlock their potential
for health and well-being at every stage of
life, they could realize their rights and
contribute to the transformative change
envisioned in the Sustainable Development
Goals (SDGs). Enabling this transformative
change is an immense task, and we all have
a role to play with countries in the lead.

I am pleased on behalf of the H6 agencies
to present the 2018 monitoring report of
the EWEC Global Strategy. The report sets        equitable access to quality services for
out the status of women’s, children’s and        sexual, reproductive, maternal, newborn,
adolescents’ health, and on health systems       child and adolescent health. Adopting a life
and social and environmental determinants.       course approach to health, which is central
Regional dashboards on 16 key indicators         to the EWEC Global Strategy, is a theme
highlight where progress is being made or        throughout the report. Collaboration across
lagging. There is progress overall, but not at   sectors is essential to address social and
the level required to achieve the 2030 goals.    environmental determinants, achieve shared
There are some areas where progress has          health and sustainable development goals
stalled or is reversing, namely neonatal         and realize human rights.
mortality, gender inequalities and health in
                                                 It is encouraging to see the work being done
humanitarian settings. The report also
                                                 through the global EWEC movement to
highlights new evidence with a special
                                                 support countries in achieving the objectives
focus on early childhood development as a
                                                 of the EWEC Global Strategy and the SDGs.
foundation for health and well-being across
the life course. There are new estimates on      The findings of this report should serve as a
the causes of death in children older than 5     renewed call to action and instil a sense of
years; most are preventable. Each section of     urgency for action and accountability at all
the report highlights strategic priorities,      levels. Only if every woman, child and
interventions and approaches that could          adolescent survives, thrives and contributes
help countries address challenges and            to transformative change will we achieve
accelerate progress.                             the 2030 SDG vision for people, prosperity
                                                 and the planet.
Integrating new evidence and evidence-based
approaches into policies and programmes is       Tedros Adhanom Ghebreyesus
important for continued progress. Universal      Director General
health coverage is the key to ensuring           World Health Organization

                                                                                  foreword       v
Survive, Thrive, TranSform - Global Strategy for Women's, Children's and adolescents' health (2016-2030) 2018 monitoring report: current status ...
     from this report

vi   Survive, Thrive, Transform - GS 2018 monitoring report: current status and strategic priorities
Survive, Thrive, TranSform - Global Strategy for Women's, Children's and adolescents' health (2016-2030) 2018 monitoring report: current status ...
This page summarizes 10 key messages              5.	Early childhood development and
based on EWEC Global Strategy monitoring             nurturing care – a foundational role.
data from 2017 and early 2018. Dashboards            Investments from pregnancy through 3
in Annex 2 signal where progress is being            years of age are the foundation of health
made or lagging.                                     and well-being throughout life.3 The new
                                                     Nurturing Care Framework will help
                                                     countries to strengthen ECD programmes.
                                                  6. The life course approach to health
Some things are not                                  – optimizing health throughout life. The
progressing or are                                   life course approach helps individuals to
                                                     optimize their health, well-being and
getting worse                                        functional ability at and across every
1.	Neonatal mortality – limited progress.            stage of life. 4 It is a connecting theme
   Rates of neonatal mortality are not               throughout this report.
   declining as quickly as mortality among
                                                  7. Continual learning and flexibility –
   children aged 1–59 months. This is a
                                                     innovation promotes change. Take note
   long-standing disparity. Multiple factors
                                                     of, and apply, new evidence of good
   contribute to neonatal mortality.
                                                     practice in women’s, children’s and
2. Gender inequalities – progress is too slow        adolescents’ health.
   and some gains are being lost. Gender-
   based inequalities and violence persist
   worldwide. Progress is reversing in some       ACTION
   areas, such as the number of women in          Build on what works and
   leadership and the economic pay gap.
   Foster equitable gender norms and
                                                  act in partnership
   address violations of rights across society.   8. UHC and health systems strengthening
                                                     – essential for progress. At least half of
3.	Humanitarian settings – many more
                                                     the world’s population lacks access to
   people are now affected by crises. The
                                                     essential health services. According to 2017
   world is witnessing the highest levels of
                                                     estimates, investments in UHC and the
   displacement on record.1 Strengthen
                                                     other SDG targets could prevent 97 million
   capacity to reduce vulnerabilities, build
                                                     premature deaths globally by 2030.5
   resilience and anticipate and respond to
   health needs in humanitarian settings.         9.	Multisectoral action – associated with
                                                     greater impact. Multisectoral action is
                                                     evident throughout this report as an
KNOWLEDGE                                            enabling factor for health. Investments
New evidence and                                     are required to understand how to apply
                                                     multisectoral approaches effectively in
interventions can                                    different settings.
accelerate progress                               10. Collaborative effort – everyone has a
4.	Older children – new evidence about                critical role to play. The objectives of
   their health and causes of death. The              the EWEC Global Strategy can only be
   causes of death of children older than 5           achieved through sustained collective
   years are mostly preventable.2 New global          action and mutual accountability at
   estimates of causes of death among                 all levels.
   older children indicate areas for action.

                                                           10 key MESSAGES from this report         vii
Survive, Thrive, TranSform - Global Strategy for Women's, Children's and adolescents' health (2016-2030) 2018 monitoring report: current status ...
Executive summary

viii   Survive, Thrive, Transform - GS 2018 monitoring report: current status and strategic priorities
Survive, Thrive, TranSform - Global Strategy for Women's, Children's and adolescents' health (2016-2030) 2018 monitoring report: current status ...
The 2018 monitoring report for the EWEC
                                                 WOMEN’S HEALTH
Global Strategy for Women’s, Children’s and
Adolescents’ Health (2016–2030) is based         Global maternal mortality fell by almost
on data from 2017 and early 2018 for the 60      44% from 1990 to 2015, but about 830
indicators in the EWEC Global Strategy           women still die daily in childbirth or as a
monitoring framework. Dashboards in              result of pregnancy or postpartum causes.
Annex 2 signal where progress is being           Evidence points to a range of other health
made or lagging.                                 challenges, including: lack of access to
                                                 modern contraceptive methods; unsafe
                                                 abortions; HIV/AIDS; cervical cancer;
EARLY CHILDHOOD                                  female genital mutilation; stillbirths; and
DEVELOPMENT                                      gender-based violence.

Early childhood development is the special       Strategic priorities
theme of the 2018 EWEC Global Strategy           ••Improve women’s health across the life
monitoring report.6,7                              course, delivering appropriate care,
                                                   support and information to women and
Scientific evidence shows that children who
                                                   their families according to needs;
lack nurturing care as part of early childhood
development may be less healthy, grow            ••Ensure a positive pregnancy experience
poorly, learn less and complete fewer grades       and improve quality of care around
at school. They may have difficulties relating     childbirth, deploying WHO guidelines on
confidently to others and earn less as adults.     antenatal and intrapartum care;

Recent research confirms that responsive         ••Ensure universal access to sexual and
care and opportunities for early learning are      reproductive health-care services;
essential components for early childhood         ••Address sexually transmitted infections by
development. The mental health and well-           eliminating mother-to-child transmission
being of carers are also critical factors.         of syphilis, controlling antimicrobial
                                                   resistance of N.gonorrhea, and
Strategic priorities                               researching new diagnostic tests and
••Implement the new Nurturing Care                 vaccines against STIs;
                                                 ••End violence against women, deploying
••Observe guidelines on early childhood            WHO clinical and policy guidelines and
  development;                                     the companion manual for health
••Develop early childhood development              system managers;
  workforce and capacity, adding newer           ••Address causes of cervical cancer by
  elements such as support for responsive          supporting introduction of the HPV
  care, early learning and caregiver health;       vaccine and HPV testing, and increasing
••Put in place comprehensive evidence-             access to treatment;
  based policies, information and services;      ••Eliminate female genital mutilation,
••Develop and use population-based                 introducing and enforcing legislation,
  indicators and a measurement framework           adopting a health systems approach to
  for early childhood development;                 ending the medicalization of FGM and
                                                   addressing social and cultural dimensions.
••Invest in research into the long-term
  effects of nurturing care interventions.

                                                                         Executive summary      ix
Survive, Thrive, TranSform - Global Strategy for Women's, Children's and adolescents' health (2016-2030) 2018 monitoring report: current status ...
CHILDREN’S HEALTH                                ••Provide comprehensive sexual and
                                                       reproductive health and rights information
    The relative lack of global progress on            and counselling for adolescents;
    neonatal mortality remains a major challenge.
                                                     ••Prevent and treat anaemia and improve
    The global under-5 mortality rate declined
                                                       assessment across age groups;
    by 56% from 93 deaths per 1000 live births in
    1990 to 41 in 2016. However, an estimated        ••Target adolescents with HIV prevention
    5.6 million children (including newborns)          and treatment programmes;
    died in 2016 before age 5. Globally, only 71%    ••Support girls’ menstrual health needs,
    of under-5s in reporting countries had their       ensuring menstruation is seen as healthy
    births registered between 2010 and 2016.           and normal and providing education
                                                       about menstruation;
    Strategic priorities
                                                     ••Prevent child marriage by introducing and
    ••Deploy and scale up proven interventions
                                                       enforcing relevant legislation, empowering
      to improve survival and health of
                                                       adolescents, fostering equitable gender
      newborns and children;
                                                       norms and promoting girls’ education.
    ••Ensure quality care during pregnancy,
      childbirth and the postnatal period,
      deploying care packages known to have          UHC, HEALTH SYSTEMS,
      the greatest impact on ending                  MAJOR DISEASES AND
      preventable neonatal deaths, stillbirths
      and long-term disability;
                                                     HUMANITARIAN SETTINGS
    ••Strengthen sectors that enable                 At least half of the world’s population still
      improvements in newborn and child              lacks access to essential health services,
      health, such as nutrition and WASH;            800 million people spend more than 10% of
                                                     their household budget on health care, and
    ••Strengthen governance and invest in
                                                     65.6 million people around the world have
      well-coordinated policies and services.
                                                     been forced from home.

                                                     Strategic priorities
                                                     ••Accelerate progress towards universal
    Global adolescent death rates have fallen by       health coverage, ensuring UHC packages
    approximately 17% since 2000 but remain            are locally designed to provide high-impact,
    highest in LMICs in Africa. Main causes of         cost-effective interventions, and include
    death are very different between younger           cross-sectoral approaches;
    (10–14 years) and older adolescents (15–19
                                                     ••Invest in health systems strengthening and
    years) and between males and females.
                                                       the health workforce, for example through
    Early marriage and early childbirth are
                                                       the education and training of midwives,
    associated with a range of maternal and
                                                       nurses and other health professionals;
    neonatal health complications.
                                                     ••Integrate a life course approach to health,
    Strategic priorities                               optimizing health, well-being and
    ••Implement the multisectoral Accelerated          functional ability throughout life;
      Action for the Health of Adolescents           ••Strengthen capacity to reduce vulnerabilities
      (AA-HA!) guidance;                               and to anticipate and respond to
    ••Engage adolescents as agents of change;          emergencies, including humanitarian crises,
                                                       based on emergency risk assessments.

x   Survive, Thrive, Transform - GS 2018 monitoring report: current status and strategic priorities
MULTISECTORAL ACTION                           Strategic priorities
In 2017, 88% of countries that supplied data   ••Foster equitable gender norms and
reported serious problems with malnutrition.     attitudes, and promote gender equity
Disparities in wealth and education, and         through appropriate channels;
environmental challenges, are barriers to      ••Adopt rights-based approaches to health
health. Multisectoral action benefits health     in health policies and programmes,
and improves communities, infrastructure         prioritizing those most in need;
and the environment.
                                               ••Strengthen health governance, focusing
Strategic priorities                             on whole-of-government responses to
                                                 ensure greater coordination and
••Adopt multisectoral approaches, such as        coherence of health plans and policies
  early childhood development programmes         with other areas of government.
  and nutrition interventions that also help
  children take advantage of education;
••Improve food systems, including              DATA MATTERS
  production, distribution, marketing and      There is an urgent need to extend and
  use and efficient food waste disposal;       strengthen data collection and analysis for
••Address environmental determinants of        women’s, children’s and adolescents’
  health through initiatives such as the       health, ensuring clarity and consistency of
  BreatheLife Campaign, the Climate and        definitions and interpretations. Improve
  Clean Air Coalition, and Global Analysis     monitoring and evaluation and
  and Assessment of Sanitation and             disaggregated data and equity analysis.
  Drinking-Water (GLAAS);
                                               Strategic priorities
••Promote girls’ education, achieving equity
                                               ••Enhance countries’ technical capacity to
  of opportunity between boys and girls;
                                                 address data challenges and to identify
••Provide comprehensive sexual and               and analyse health inequalities or
  reproductive health and rights information     observed differences between subgroups;
  and counselling as part of health and
                                               ••Consider deploying the WHO Health
  multisectoral action, in school and in
                                                 Equity Assessment Toolkit (HEAT), the
  wider society.
                                                 WHO Health Equity Monitor database and
                                                 the UNICEF Equitable Impact Sensitive
EQUITY, GENDER, RIGHTS                           Tool (EQUIST), in tandem with country
                                                 health information systems;
                                               ••Strengthen country data systems and use.
Persistent health, economic, gender, social,     Invest in civil registration and vital
racial and educational inequities worldwide      statistics, health information, and local
are barriers to achieving the 2030 Agenda.       capacities to analyse and use data.
The implementation of human rights and
good governance are central to its aims.

      The findings and analysis contained in this report are based on the latest data
     viewable on the EWEC Global Strategy portal of the Global Health Observatory:

                                                                       Executive summary     xi

1   Survive, Thrive, Transform - GS 2018 monitoring report: current status and strategic priorities
This is the 2018 monitoring report for the      1. Country leadership
EWEC Global Strategy for Women’s, Children’s
                                                2. Individual potential
and Adolescents’ Health (2016–2030). It
highlights the latest available data through    3. Humanitarian and fragile settings
2017, and to May 2018, for the 60 indicators    4. Financing for health
in the EWEC Global Strategy monitoring
                                                5. Community engagement
framework. Dashboards signal where
progress is being made or lagging (Annex 2),    6. Research and innovation
and the report flags priorities for policy,     7. Health system resilience
investment and implementation in 2018 and
                                                8. Multisector action
beyond. More detailed data for all countries
is available on the EWEC Global Strategy        9. Accountability.
portal of the Global Health Observatory at:
                                                These action areas are key to making
                                                progress across a core set of interlinked
In addition to reporting on women’s,            areas and maximizing synergies in the
children’s and adolescents’ health overall,     provision and utilization of information,
each monitoring report has a special theme      goods and services.
based on priorities identified by Member
                                                This approach dovetails with the latest
States at the World Health Assembly and by
                                                scientific evidence,3 which confirms that
the multistakeholder EWEC community.
                                                early childhood development is
This year the special theme is early
                                                foundational to the improvement of health
childhood development (ECD) – one of the
                                                and human capital across the life course,
six focus areas highlighted in the 2020 EWEC
                                                especially when delivered in an enabling
Partners Framework (Annex 1). In 2019 the
                                                environment through integrated,
theme will be midwifery care.
                                                multisectoral programmes and at the right
Early childhood is a critical phase in life,    critical stage.8
when evidence-based interventions that
                                                While this report provides an overview of
target risk factors can improve human
                                                progress towards EWEC Global Strategy
capital across the life course.8 Investing in
                                                targets and indicates how they relate to
these interventions can result in a triple
                                                SDG monitoring and baselines, the latter are
dividend – with health, social and economic
                                                still being finalized for some SDG targets so
benefits – for people now, for their future
                                                comparison is not always possible.
and for the next generation. Investments in
newborn care, early childhood, child and        The next section summarizes the latest
adolescent health and development, and          evidence for early childhood development
family planning, pregnancy and childbirth       and highlights the importance of nurturing
care can yield benefit-to-cost ratios of at     care. Subsequent sections present the
least 10-to-1.3,9,10                            status of action on the objectives of the
                                                EWEC Global Strategy. Each section
To achieve these transformational benefits,
                                                begins with an overview, and then outlines
it will be necessary to develop innovative
                                                new developments and strategic priorities
and collaborative approaches that reflect
                                                for action.
the Survive, Thrive and Transform
objectives of the Global Strategy and its
nine action areas:

                                                                              Introduction      2

    Early childhood
    The foundation of improved
    health and human potential for
    current and future generations

3   Survive, Thrive, Transform - GS 2018 monitoring report: current status and strategic priorities
Over the last three decades, scientific           The series emphasized “nurturing care”,
findings from a range of disciplines have         especially from pregnancy to 3 years, and
confirmed that early childhood                    the important role of the health sector and
development lays the foundation for health,       multisectoral interventions.
learning, productivity and well-being
throughout a person’s life.3                      What is nurturing care?
An optimal environment supports                   Nurturing care refers to the conditions
children’s brain development, while an            created by public policies, services and
adverse environment harms development,            programmes to enable communities and
in the short term and in the long term. The       caregivers to ensure children’s good health
period from pregnancy to 3 years is when          and nutrition, protect them from threats,
children are most susceptible to                  and give young children opportunities for
environmental influences.                         early learning, through interactions that are
                                                  emotionally supportive and responsive.
Negative factors reduce the capacity of
families and other caregivers to protect,         Nurturing care promotes young children’s
support and promote young children’s              health and development and protects them
health and development. Moreover, threats         from the worst effects of adversity by
to early childhood development tend to            reducing stress and boosting emotional and
cluster together, often in conjunction with       cognitive coping mechanisms. It is especially
social exclusion and lack of services.11          important for children with developmental
                                                  difficulties and disabilities, as well as for
However, children who face early adversity        prevention of child maltreatment.
need not fall further and further behind.
Commitment to early childhood
development can be the catalyst to enable         Figure 1
children to thrive, and thereby transform
health and human potential.
                                                  The components of nurturing care

Effective investments in the early years are
the cornerstone of human development and
are essential to reduce inequities in health
and economic achievement. Failure to so
invest has profound economic and social
costs that aggregate across society and                        Good                   Adequate
                                                               health                 nutrition
into the next generations.12
                                                                        of nurturing
What’s new?
The 2016 Lancet series, Advancing Early              Opportunities                         Responsive
Childhood Development: from Science to                 for early                           caregiving
Scale, proposed a set of recommendations
for promoting, protecting and supporting
early childhood development at scale.                                     Security
                                                                         and safety

                                               SPECIAL THEME: early childhood development               4
The science behind                                  Current status
    nurturing care
                                                        Risk factors to early
    Babies are born with almost all the neurons         childhood development and
    they will ever have. By 2 years, massive
                                                        children at risk
    numbers of neuronal connections have been
    made in response to stimulation from                Many things can threaten the development
    caregivers. This rapid brain development is         of young children, beginning in and even
    an established genetic pattern, but it is           before pregnancy. These include
    shaped by the young child’s experiences.            inadequate maternal nutrition, exposure to
                                                        environmental pollutants, HIV infection,
    Children acquire basic learning and social skills
                                                        poor caregiver mental and physical health,
    at an early age. These competencies make it
                                                        suboptimal breastfeeding, malnutrition,
    easier to learn new skills, and build confidence
                                                        illnesses, injuries, limited stimulation,
    and the motivation to learn more. Long-term
                                                        neglect and maltreatment. Adversity in
    studies in countries across the socioeconomic
                                                        pregnancy leads to low birthweight and
    spectrum show that nutritional and
                                                        preterm birth, which raises the risk of
    psychosocial programmes, implemented from
                                                        developmental difficulties and chronic
    pregnancy, have significant benefits for adult
                                                        diseases in adulthood. Care given to
    health and well-being, schooling and earnings,
                                                        women and men to ensure they are in
    personal relationships and social life.12
                                                        good health before they conceive a child is
    Early intervention is effective and also            also essential.
    makes later essential interventions more
                                                        It is estimated that at least 250 million
    cost-effective and more likely to succeed.
                                                        children younger than 5 years of age (or
    Estimates show that some countries spend
                                                        43%) are at risk of suboptimal development
    less on health now than they will lose in
                                                        in LMICs,3 due to risk factors of poverty or
    future from poor growth and development
                                                        stunting alone. Globally, 25% of children are
    in early childhood.12
                                                        living in extreme poverty, with prevalence
    Protecting, promoting and                           as high as 72.3% in sub-Saharan Africa and
                                                        46.5% in South Asia.13 While stunting is
    supporting nurturing care
                                                        declining in almost every region, progress
    Caregivers need knowledge, time and                 varies considerably; 22% of children under-5
    resources to provide nurturing care. Laws,          worldwide suffer from moderate and severe
    policies, services, community activities and        stunting, representing 151 million stunted
    social relationships create enabling                children. Two out of five stunted children in
    environments, support caregiving, and               the world live in Southern Asia.14
    strengthen caregiver-child relationships.
                                                        Many health and nutrition interventions for
    Nurturing care also requires engagement             women, children and adolescents affect
    across a range of sectors – including health,       young children’s brain development. This
    nutrition, education, child protection, social      report shows ample data to illustrate critical
    protection, labour and finance. It calls for        gaps in coverage.
    concerted effort by many stakeholders –
                                                        Comparable data on children’s developmental
    including governments, civil society, academic
                                                        status, using the early childhood development
    institutions, the private sector, families and
                                                        index (ECDI) are currently available for 66
    others providing care for young children – at
                                                        LMICs (UNICEF multi indicator cluster surveys).
    the local, national, regional and global levels.

5   Survive, Thrive, Transform - GS 2018 monitoring report: current status and strategic priorities
The proportion of children who are                                                          Seventy-two events and academic
developmentally on track overall varies                                                     presentations have been held worldwide
widely across countries.15 It is important to                                               since October 2016 to discuss the series’
note that the ECDI is currently under review                                                key messages (Figure 2). Twenty-four
and a stronger metric will become available                                                 countries hosted a national event, while five
in the near future to cover children aged                                                   regional conferences and six global events
0–59 months.                                                                                reached many more national policy-makers
                                                                                            and other stakeholders.

                                                                                            Follow-up to document the impact of these
Progress in                                                                                 events on policies and programming in
investment and                                                                              countries and at global level is underway.
                                                                                            An example is the decree of the
country programming                                                                         Government of Mexico, fully endorsing the
                                                                                            Nurturing Care framework as the basis for
Uptake of the key messages of
                                                                                            initial education in Mexico.16
the Lancet ECD series
                                                                                            Global institutions – including UNICEF, the
Since the launch of the Lancet ECD series on
                                                                                            World Bank, UNESCO and WHO – have
5 October 2016, early childhood
                                                                                            prioritized early childhood development in
development – and the nurturing care
                                                                                            their future global programmes of work.
agenda in particular – has attracted the
                                                                                            The launch of the Early Moments Matter
attention of a range of stakeholders
                                                                                            report by UNICEF in September 2017 was
interested in disseminating and applying
                                                                                            a milestone.13
the new evidence.

Figure 2
Disseminating and applying the new evidence
(number of global events to launch the Lancet ECD series)


                                        1 1                                                 1
                                                                                        1                                   2
        1           1           1       6         1
    1                               1         1
                        1               6                                               1
        1                                                                                                         1         1
                    1               1                                                                         2                 1
                5                                                      1
                        1                                 1
                            2                                                       1
                                    1                                      1

                                                      1                                                   1
                                                                   1                                      2
                                                               1                                    1

                                                                                                    1 1

                                            1                                               2

                                                                                                                                    Source: WHO, 2018

                                                                                SPECIAL THEME: early childhood development                                  6
A global framework for                           Countries with comprehensive
    nurturing care                                   policies for ECD
    To provide a roadmap for action, WHO and         An updated assessment in December 2017
    UNICEF – supported by the Partnership for        indicated that 75 countries had a
    Maternal, Newborn & Child Health and the         multisectoral early childhood development
    ECD Action Network – started to develop a        policy instrument in place (up from 48 in
    Nurturing Care Framework in 2017. Two            2007 and 68 in 2014), either as a national
    global online consultations and face-to-face     policy, a strategic plan, or a law.18 These
    consultations in several regions were held       provide a basis for promoting a
    to elicit inputs from stakeholders. The          comprehensive agenda for early childhood
    Framework was due for launch during the          development addressing services across
    71 st World Health Assembly in May 2018.         the life course to age 8, increasingly with a
    It will be accompanied by an online service      strong emphasis on the critical period from
    through which relevant guidelines,               preconception through age 3.
    operational guidance, indicators and a
    measurement framework, country profiles          Scaling up interventions
    and stories can be accessed.17                   Many health-care and nutrition services, as
                                                     well as some provisions for security and safety,
                                                     are already in place in countries, though their
                                                     coverage and quality must be improved.

    Care for Child Development

    WHO and UNICEF developed the materials
    of Care for Child Development (CCD).
    They include age- and developmentally
    appropriate recommendations on play and
    communication that guide counsellors in
    helping caregivers interact with their
    children. By 2014, CCD had been
    introduced in more than 25 countries using
    multiple contact points in health, nutrition,
    pre-school education, social welfare and
    child protection programmes. In no country
    was a new cadre of worker created; rather
    the intervention was integrated into
    existing services.19 Other countries have
    since built capacity for CCD, in particular in
    sub-Saharan Africa and the Americas.

7   Survive, Thrive, Transform - GS 2018 monitoring report: current status and strategic priorities
What is new is the understanding that
                                                   Strategic priorities
responsive caregiving and opportunities for
early learning are essential components of         The EWEC Global Strategy and the SDGs
daily care for young children. Responsive          provide the impetus for governments and
caregiving is also the basis for supporting        the global community to step up smart
families of children with developmental            investments for early childhood development.
difficulties and disabilities, for preventing      The Nurturing Care Framework calls upon
maltreatment, and for protecting children          governments and other stakeholders to
against stress and injury.20                       take action in five areas:

Good mental health and strong motivation           1. Provide leadership, create commitment
are important for caregivers to be able to            and invest;
empathize with a young child’s experiences.        2. Place families and communities at the
Up to a third of women who are pregnant or            centre;
who have recently given birth experience
                                                   3. Strengthen existing systems and services;
depression. Effective interventions to
reduce depression and promote maternal             4. Monitor progress;
mental health have been developed and              5. Strengthen local evidence and innovate
tested in LMICs where there are very few              to achieve scale.
mental health specialists, and are generally
implemented by trained community health            Implementing the Nurturing Care Framework
workers under professional supervision.21          to strengthen country programmes for early
Interventions designed to improve maternal         childhood development is a top priority.
mental health have a positive impact on            In order to support the translation of the
infant health and development, and                 Framework into country actions, WHO,
interventions to promote infant health and         UNICEF and a host of experts and partners
development positively impact maternal             are working together to expand resources
mood. They have the greatest effect when           and stimulate investments. Activities include
implemented together.                              the provision of guidelines, operational
                                                   guidance, new population-based indicators
Monitoring progress                                and a measurement framework, and support
                                                   for workforce capacity and new research.
There is a need for more population-based,
comparable data to assess global progress          The nurturing care framework and additional
in early childhood development. For the            information on ECD are available from:
first time, a subgroup of the Lancet ECD 
Steering Team in collaboration with the            adolescent/child/nurturing-care-
Countdown to 2030 has developed country            framework/en/.
profiles for 91 countries. They bring
together data on demographics, prevalence          An interactive online service is in preparation
and inequality of risk factors, support for        at to enable easy
enabling environments through policies and         access to relevant resources and new
services, and coverage of essential                information, including tools and experiences
interventions for nurturing care.17                from countries.

                                                SPECIAL THEME: early childhood development           8
Women’s health

9   Survive, Thrive, Transform - GS 2018 monitoring report: current status and strategic priorities
A primary target of the EWEC Global              In 2012, 528 000 new cases of cervical
Strategy and SDG 3 is the reduction of           cancer were diagnosed and 266 000
preventable maternal mortality. Based on         women died of the disease, nearly 90% of
the latest available estimates, there were       them in LMICs. Many women have no access
303 000 maternal deaths in 2015, and a           to services for prevention, curative treatment
decline in the estimated ratio of maternal       or palliative care. The primary cause of
deaths per 100 000 live births from 385 in       cervical pre-cancer and cancer is human
1990 to 216 in 2015 (SDG 3.1.1). Sub-Saharan     papillomavirus (HPV), which is a vaccine-
Africa remains the region with the highest       preventable infection and the most common
ratio, at 555 per 100 000 live births –          sexually transmitted infection (STI).29
almost triple that of the next highest.22
                                                 Violence against women remains one of the
Of the more than 830 women who daily die         major threats to women’s health and well-
in childbirth or as a result of pregnancy and    being (SDG 5.2.1). Global estimates
delivery,22 most die from postpartum             published by WHO in 2013 indicate that
haemorrhage, hypertensive disorders,             35% of women worldwide have experienced
infection and complications from delivery or     either physical and/or sexual intimate
abortion.23 Others die from the interaction      partner violence or non-partner sexual
between pregnancy and pre-existing health        violence in their lifetime. Most of this was
conditions, or suffer complications from         intimate partner violence.30 Intimate partner
pregnancy that continue after childbirth,        violence often persists into or can start
including health conditions such as infection    during pregnancy. The global prevalence of
and depression.24                                physical and/or sexual intimate partner
                                                 violence among all ever-partnered women
Stillbirths are also a major concern, with an
                                                 is estimated at 30%.30 During pregnancy,
estimated 2.6 million in 2015. Half occurred
                                                 the prevalence of intimate partner violence
during labour and birth, mostly from
                                                 ranges across countries from 2–57%.31-33
preventable conditions, and mostly in
LMICs.25 In 2015, the stillbirth rate per 1000   At least 200 million girls and women have
live births was 18 globally, and was highest     undergone female genital mutilation (FGM),
in sub-Saharan Africa at 29/1000.                including about one in three of girls aged
                                                 15–19 years in 30 countries in which the
In other areas of sexual and reproductive
                                                 practice is concentrated.15,34 Only half of all
health, an estimated 214 million women of
                                                 women aged 15–49 years (married or in
reproductive age in LMICs who want to
                                                 union) in 45 countries reporting data, make
avoid pregnancy are not using a modern
                                                 their own decisions regarding sexual
contraceptive method.26 According to a
                                                 relations, contraceptive use and health
study published in the Lancet in September
                                                 care.34 More girls are likely to undergo FGM
2017, an estimated 25 million (or 45%) of all
                                                 every year over the next 15 years due to
abortions every year worldwide between
                                                 population growth.35
2010 to 2014 were unsafe.27

AIDS-related illnesses remain the leading
cause of death among women of
                                                 What’s new?
reproductive age (15–49 years) globally, and
they are the second leading cause of death       Contraception – In 2018, an estimated 77% of
for young women aged 15–24 years in Africa.28    women of reproductive age who are married

                                                                              Women’s health       10
or in-union have their family planning needs       Safe abortion – Over 75% of abortions in
     met with a modern contraceptive method.36          Africa and Latin America were unsafe, and in
     Achieving universal access to sexual and           Africa nearly half of all abortions were
     reproductive health services by 2030 will          performed by untrained persons using
     require intensified support for family planning,   traditional and invasive methods.27 To raise
     including through the implementation of            standards worldwide, a new open-access
     effective government policies and                  Global Abortion Policies Database was
     programmes.37 Access to emergency                  launched in June 2017, containing abortion
     contraception remains limited.38                   laws, policies, health standards and
                                                        guidelines for all WHO and United Nations
     Antenatal and intrapartum care – In 2017,
                                                        Member States. 43
     an estimated 62% of pregnant women
     received four or more antenatal visits.39 In       HIV prevention and testing – New data
     2013, 59% sought care early in pregnancy. 40       from a study in eastern and southern Africa
     In 2015, more than 95% of women in 49              has highlighted the importance of HIV
     countries were screened for syphilis.              prevention and testing for pregnant and
     However, in high-morbidity countries in            postpartum women. The research found
     sub-Saharan Africa the percentage of               that a woman’s risk of acquiring HIV through
     pregnant women screened and treated for            sex with a male partner living with HIV
     syphilis was only
are in the process of revising the indicators      and rights to make decisions about their
and approaches for tracking emergency              own health should be respected, promoted
obstetric care, given that the majority of         and protected. 49,50
births now take place in health care facilities.
                                                   Address sexually transmitted infections –
                                                   Eliminate mother-to-child transmission of
                                                   syphilis, control antimicrobial resistance of
Strategic priorities                               N.gonorrhea, and research new diagnostic
                                                   tests and vaccines against STIs. WHO has set
Improve women’s health across the life
                                                   targets for achievement by 2030: 1) a 90%
course – Delivering appropriate care,
                                                   reduction of syphilis incidence; 2) a 90%
support and information to women and their
                                                   reduction in gonorrhoea incidence; and 3)
families according to needs throughout the
                                                   50 or fewer cases of congenital syphilis per
life course is critical to achieving health
                                                   100 000 live births in 80% of countries.51
goals. Priorities for strategic reframing of
health systems and health-care delivery            End violence against women – Prevention
include: 1) promoting a healthy lifestyle          of and response to violence against women
(including adequate nutrition); 2) prevention,     remains an ongoing priority and is critical to
testing and management of health conditions        achieving women’s and children’s health
such as HIV, diabetes and hypertension;            goals. Governments have recognized this as
3) family planning/contraception counselling       an urgent public health priority and are
and services; 4) care and support for women        updating their protocols and training of
experiencing intimate partner violence;            health providers.52,53
5) preventing diseases though immunization
                                                   Address causes of cervical cancer –
or detection.
                                                   Support introduction of the HPV vaccine
Ensure a positive pregnancy experience             and HPV testing and increase access to
and improve quality of care around                 treatment. The core principle of a
childbirth – Lack of skilled care, including       comprehensive approach to cervical cancer
emergency obstetric and neonatal care, is a        prevention and control is to act across the
major obstacle to better health for women.         life course to deliver age-appropriate and
Strengthened health systems and a fully            effective interventions. A comprehensive
staffed, qualified health workforce –              programme includes primary, secondary
particularly midwives educated and                 and tertiary prevention.29,54
regulated to international standards – are
                                                   Eliminate female genital mutilation – FGM
required to provide quality care around
                                                   can result in health complications that affect
childbirth. WHO guidelines on antenatal
                                                   obstetric, gynaecological, psychological
and intrapartum care are available. 47,48
                                                   and sexual health. Momentum exists
Ensure universal access to sexual and              towards the complete abandonment of the
reproductive health-care services – All            practice, including legislation adopted in 26
women and adolescent girls have the right          of 30 high-prevalence countries. Primary
to freely access sexual and reproductive           prevention of FGM includes preventing
health services. Freely available information      medicalization of the practice and
and services are essential to informed             addressing social and cultural dimensions.55,56
decision-making for sexual and
reproductive behaviours and practices,
including birth spacing. Women’s autonomy

                                                                               Women’s health        12
Children’s health

13   Survive, Thrive, Transform - GS 2018 monitoring report: current status and strategic priorities
The relative lack of global progress on             A legal identity is a fundamental human
neonatal mortality is one of the most               right. Not having a legal identity affects an
significant challenges indentified in this          individual’s ability to access basic health
report. Children face the highest risk of           care, education and employment and is a
dying in their first month of life, with the        major factor contributing to poor health
majority of deaths in the first week of life.2      outcomes in children. The proportion of
The global neonatal mortality rate fell by          children under-5 whose births have been
49% from 37 deaths per 1000 live births in          registered is the indicator that captures
1990 to 19 in 2016 (SDG 3.2.2). Sub-Saharan         progress towards providing a legal identity
Africa and Central and South Asia remain            for all by 2030 (SDG 16.9.1). Globally, only
the worst affected regions, at 28/1000 and          71% of under-5s in reporting countries had
27/1000 respectively.                               their births registered between 2010 and
                                                    2016.58 According to global UNICEF figures
The main causes of newborn mortality are
                                                    (based on DHS, MICS, other national
prematurity and intrapartum-related
                                                    household surveys, censuses and CRVS
complications, including birth asphyxia and
                                                    systems) sub-Saharan Africa had the lowest
birth trauma. The main killers of children
                                                    percentage of births registered (43%)
under-5 in 2016 included preterm birth
                                                    followed by South Asia (60%) and East Asia
complications, pneumonia, intrapartum-
                                                    and Pacific (excluding China) (84%). Western
related events, diarrhoea, neonatal sepsis
                                                    Europe and North America, Australia and
and malaria.2
                                                    New Zealand had 100% of births registered
The global under-5 mortality rate declined          for the same reporting period.15
by 56% from 93 deaths per 1000 live births
in 1990 to 41 in 2016 (SDG 3.2.1). Sub-
Saharan Africa remains the worst affected
                                                    What’s new?
region, at 79 deaths per 1000 live births.
The majority of regions in the world (and           Mortality in early childhood – In 2016, an
142 out of 195 countries) at least halved           estimated 5.6 million children (including
their under-5 mortality rate.2                      newborns) died before reaching their fifth
                                                    birthday, mostly from preventable diseases.
When they survive beyond 5 years, older
                                                    Approximately 80% of these deaths
children in LMICs face long-term health risks,
                                                    occurred in two regions: sub-Saharan Africa
including infectious diseases and suboptimal
                                                    and Southern Asia. All six countries with an
development due to poverty and stunting.
                                                    under-5 mortality rate above 100 per 1000
The global prevalence of under-5 stunting is
                                                    live births are in sub-Saharan Africa.2
22% (SDG 2.2.1) representing 151 million
stunted children. Two out of five stunted           Globally, 2.6 million children died in the first
children in the world live in Southern Asia.14,57   month of life in 2016 with most occurring in
The Lancet series on early childhood                the first week, representing 47% of
development (2016) indicates that in LMICs in       mortality in children under-5. Neonatal
2010, 250 million children, or 43%, were at risk    mortality declined globally in 2016 but
of suboptimal development due to poverty            more slowly than mortality among children
and stunting.3 This proportion increases if         aged 1–59 months. The decline in the
other risk factors such as low maternal             neonatal mortality rate from 1990 to 2016
education or violence are considered.               was slower than the decline in mortality

                                                                               Children’s health       14
among children aged 1–59 months (49%                 Mortality in older childhood – An analysis
     compared with 62%). This pattern is                  of deaths of children aged 5–9 years shows
     consistent across regions with sub-Saharan           that infectious diseases such as lower
     Africa and Oceania (excluding Australia and          respiratory infections, diarrhoeal diseases
     New Zealand) having a decline in neonatal            and meningitis remain among the leading
     mortality that was slower than other regions.        causes of death globally, but that injury-
                                                          related causes such as drowning and road
     Eighty per cent of all neonates (under 28
                                                          traffic injury are increasing.28
     days) die from prematurity, birth asphyxia
     and neonatal sepsis (Figure 3).59 For children       Recent estimates include, for the first time,
     aged 1–59 months, acute respiratory                  deaths for children aged 5–14 years.2 In 2016,
     infections and diarrhoea remain the biggest          1 million in this age group died mainly from
     killers. Ending preventable child deaths can         preventable causes.28 This translates into
     be achieved by: providing immediate and              3000 older children dying every day. There
     exclusive breastfeeding; improving access            are very few global analyses of levels of the
     to skilled health professionals for antenatal,       causes of death among older children.
     birth and postnatal care; improving                  These estimates are needed if we are to
     nutrition; promoting knowledge of danger             achieve the same level of reductions in
     signs among family members; improving                mortality and burden of disease among
     access to water, sanitation and hygiene;             older children as for children under-5.
     and providing full immunization coverage.
                                                          The largest number of older children died in
     Many of these lifesaving interventions are
                                                          LMICs in Africa, where the death rates for
     not fully implemented in the world’s
                                                          both boys and girls are significantly higher
     poorest communities.
                                                          than in any other region. However, there are
                                                          regional differences in both magnitude and

     Figure 3
     Main causes of child mortality under 5 years

                                         Source: WHO-MCEE methods and data sources for child causes of death 2000–2016
                                                    (Global Health Estimates Technical Paper WHO/HMM/IER/GHE/2018.1)

15   Survive, Thrive, Transform - GS 2018 monitoring report: current status and strategic priorities
Figure 4
Estimated top five causes of death for older children aged 5–9 years by sex
(rates per 100 000), 201528

                                                             Source: WHO – Global Health Estimates 201528

cause of death. Drowning is the leading cause   Ensure quality care during pregnancy,
of death in LMICs in South-East Asia and        childbirth and the postnatal period –
Western Pacific, while collective violence      Deploy the packages of care known to have
and legal intervention (war and terrorism)      the greatest impact to prevent more than 1.9
are the leading causes of death for older       million maternal and newborn deaths and
children in Eastern Mediterranean LMICs.        stillbirths by 2025 with universal access.
                                                Postnatal care provides the delivery platform
                                                for promotion of healthy practices, routine
                                                care of mother and newborn, and detection
Strategic priorities                            of problems requiring additional care. An
Deploy and scale up proven interventions –      example is the Baby-Friendly Hospital
A variety of evidence-based interventions       Initiative to support breastfeeding.60
are known to be effective to reduce child
                                                Strengthen sectors that enable
mortality, and remain an ongoing priority
                                                improvements in newborn and child health
for implementation. Effective interventions
                                                – Invest in sectors related to health, such as
for improving survival and health of
                                                nutrition, WASH, education, energy and
newborns and children are part of the
                                                child and social protection.
packages of integrated services for
reproductive, maternal, newborn, child and      Strengthen governance – Invest in well-
adolescent health (RMNCAH).                     coordinated policies and services.

                                                                              Children’s health             16
Adolescents’ health

17   Survive, Thrive, Transform - GS 2018 monitoring report: current status and strategic priorities
The 1.2 billion adolescents (10–19 years) in    Demand for family planning satisfied by
the world today represent more than 18% of      modern methods is generally lower
the global population. In 2015, more than       among girls aged 15–19 years compared to
1.2 million adolescents died.61                 older women.67

Main causes of adolescent deaths include        Globally, 260 000 adolescents aged 15–19
road injury, lower respiratory infections,      years became newly infected with HIV in
self-harm, diarrhoeal diseases, drowning,       2016, contributing 12% to all 2.1 million
interpersonal violence and maternal             adolescents living with HIV.15 About 80% of
conditions.28,61 Leading risk factors differ    the global total is in sub-Saharan Africa.68
between younger and older adolescents.          Compared to children and adults,
Younger adolescents globally are at risk        adolescents living with HIV have poorer
from unsafe water and sanitation,               retention in care, lower rates of viral
inadequate hand washing and household air       suppression and higher rates of mortality.68
pollution. For older adolescents, the main
                                                Gender-based violence against adolescents
risk factors are alcohol use, unsafe sex and
                                                is a major problem, and the lifetime
unsafe water and sanitation.62
                                                prevalence of intimate partner violence
Global adolescent mortality rates have fallen   among girls aged 15–19 years is 29%.30
by approximately 17% since 2000 to 101 per
                                                Iron-deficiency anaemia is the leading cause
100 000 in 2015. Rates remain highest in
                                                of disability-adjusted life years (DALYs) lost
LMICs in Africa, at 243 per 100 000. Eastern
                                                for girls and boys aged 10–14 and for girls
Mediterranean LMICs are second-highest at
                                                aged 15-19.28
115 per 100 000. The lowest rates are in
Western Pacific LMICs (40 per 100 000) and      Both younger and older adolescents suffer
high-income countries (24 per 100 000).61       the burden of mental health problems.
                                                Self-harm is a leading cause of death for
According to the latest UNICEF estimates,
                                                older adolescent girls and boys worldwide.61
25 million child marriages were prevented in
the last decade due to accelerated progress     Risk factors for noncommunicable diseases
to eliminate the practice. However, about       (NCDs), the leading cause of premature
12 million girls still marry each year before   adult deaths, are often acquired in
the age of 18.15,63 An estimated 21 million     adolescence. They include tobacco use,
girls aged 15–19 years become pregnant          unhealthy diet and physical inactivity, which
each year in developing regions; about half     lead to an increased risk of overweight and
of these pregnancies are unintended. The        obesity, diabetes and raised blood pressure,
birth rate for women aged 15–19 years is 44     and ultimately to a higher risk of NCDs
per 1000 globally, and highest in sub-          across the life course.69
Saharan Africa at 101 per 1000 (SDG 3.7.2).
                                                An estimated 60 million young adolescents
Early childbirth is associated with a range     of lower secondary school age and 142
of maternal and neonatal health                 million of upper secondary age are out of
complications.64,65 There were 25.1 million     school, based on 2016 figures. The children
unsafe abortions each year between 2010         who are not enrolled in school are often
and 2014.27 An estimated 15% of all unsafe      those from the most socially marginalized
abortions are in girls aged 15–19 years.66      communities and backgrounds.61

                                                                      Adolescents’ health        18
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