World Health Organisation
Equity is at the heart of the 2030 Agenda for Sustainable Development. In pledging to achieve the Sustainable Development Goals (SDGs), countries have committed to leave no one behind. It is of particular importance that paragraph 26 of the 2030 Agenda states: “To promote physical and mental health and well-being, and to extend life expectancy for all, we must achieve universal health coverage and access to quality health care. No one must be left behind”, thus highlighting the role of health sector in addressing the needs of the most disadvantaged and vulnerable. In addition, the SDG 3 focuses on ensuring healthy lives for all at all ages, positioning equity as a central issue in health, contributing to reducing inequality within and between countries to promote the inclusion and empowerment of all.
“Leaving no one behind” requires identifying, understanding and addressing of health inequities between and within countries and between people themselves, wherever they live. It means looking deep into health sector, but also into all aspects of people’s lives – conditions in which people are born, grow, work, live and age – as political, economic, social, environmental determinants which shape the conditions of daily lives.
The work of the World Health Organization focusses on the needs of all peoples since its very beginning. The WHO Constitution itself is based on 9 principles which are as relevant today for the sustainable development agenda as they were almost 70 years ago. Throughout the intervening years, WHO and its Member States have consistently re-affirmed their commitment to improve health of all peoples, by adopting the Declaration of Alma-Ata in 1978, the Global Strategy for Health for All in 1981, through the Commission on Social Determinants of Health and its findings in 2008, to name but a few.
The latest World Health Statistics 2016: Monitoring Health for the SDGs , finds that global life expectancy for children born in 2015 was 71.4 years (73.8 years for females and 69.1 years for males), but an individual child’s outlook depends on where he or she is born. The report shows that newborns in 29 countries – all of them high-income -- have an average life expectancy of 80 years or more, while newborns in 22 others – all of them in sub-Saharan Africa -- have life expectancy of less than 60 years. We will keep monitoring and reporting on these kind of health inequities.
Universal health coverage is the single most powerful concept in public health. It’s goal is to ensure that all people obtain the health services they need without suffering financial hardship when paying for them. It includes health protection, promotion, prevention, treatment, rehabilitation and palliation. Universal health coverage is the target that underpins and key to the achievement of all other health-related goals and targets by increasing coherence, reducing fragmentation, and contributing to the development of strong health systems.
WHO leads global efforts to develop standards for quality of care with accompanying implementation guidances, as well as a measurement framework for assessing progress globally and in countries. WHO-coordinated research underpins normative guidance and support to countries to accelerate progress.
Some specific comments on questions in the provided template include:
(a) An assessment of the situation regarding the principle of “ensuring that no one is left behind” at the global level
The Tracking Universal Health Coverage report and the World Health Statistics 2016 show that many countries are still far from universal health coverage as measured by an index of access to 16 essential services, especially in the African and eastern Mediterranean regions. Globally, 400 million people do not have access to essential health services. Furthermore, 6% of people in low- and middle-income countries are tipped into or pushed further into extreme poverty because they incur catastrophic health expenses, defined as out-of-pocket health costs that exceed 25% of total household spending, when they use health services.
Globally, the MDGs’ targets for HIV, tuberculosis and malaria have been met. Child mortality has fallen by 53% and maternal mortality by 44%. However, progress within and between individual countries is highly variable.
Based on the WHO Monitoring of the achievement of the health-related MDGs we would like to highlight, in this context, the “un-finished” part of the MDG agenda:
- Globally, under-five mortality is 43 deaths per 1000 live births;
- The proportion of underweight children is 14% - globally 156 million children under 5 are stunted, and 42 million children under 5 are overweight . Under-nutrition causally contributes to an estimated 45% of all deaths among children under five years of age;
- Neonatal mortality rates decline is slower than that for child mortality overall, and the proportion of deaths in children under five years of age that occur in the neonatal period increased from 40% in 1990 to 45% in 2015. Leading causes of under-five mortality are prematurity (18%), acute respiratory infections (16%), interpartum-related complications (12%), diarrhoea (9%), malaria (7%), and congenital anomalies (8%);
- The number of women dying because of complications during pregnancy is estimated at 303 000 in 2015;
- In 2015, 24% of married or in-union women who wanted to stop or postpone childbearing were not using modern contraception;
- In 2014, an estimated 2.0 million people became newly infected with HIV
- In 2015, an estimated 214 million cases of malaria led to 438 000 deaths globally;
- In 2013, 278 million of the 840 million people at risk of malaria in sub-Saharan Africa lived in households without even a single insecticide-treated bednet; 15 million of the 35 million pregnant women did not receive preventive treatment; and between 56 and 69 million children with malaria did not receive artemisinin-based combination therapies;
- 1.8 billion people still drink contaminated water, and 946 million people defecate in the open;
- According to WHO estimates , climate change will cause an additional 250 000 deaths per year between 2030 and 2050.
(b) The identification of gaps, areas requiring urgent attention, risks and challenges
The report Health in 2015: from MDGs, Millennium Development Goals to SDGs, Sustainable Development Goals identifies a number of challenges for the coming 15 years, based on the trends and positive forces since 2000, as well as some emerging challenges. It starts with broader economic, social and environment determinants of health, but also looks into specific gaps and challenges in health sector.
For example, gender equality and rights are major health determinant with the strong relationship between the status of women and their education, and health outcomes for the whole family and community. Health sector needs to strengthen its capacity to: enhance data and statistics; increase access to quality health care; support caregiving role; eliminate harmful practices; combat violence against women; and introduce gender-sensitive policies.
Reinforcing key health system functions in improved management of environmental determinants, such as water and sanitation, disease surveillance, preparedness and response for extreme weather events, can avert some of the potential burden to health system, but also to economic progress.
When it comes to health systems, fragmentation of country health systems that resulted from the establishment of separate programmes, each focusing on its own targets, with little consideration for their impact on the health system as a whole, is of great concern. This situation is exacerbated when each programme produces a separate estimate of financial needs – geared primarily to advocacy rather than accurate budgeting.
Addressing health system weaknesses is of utmost importance for ensuring equity in health outcomes across different population groups. Access to services is low for rural populations and the poor, and management inefficiencies account for substandard delivery of care. Health financing, inadequate human resources, inadequate investment in research and development and inadequate medical products, lack of health systems resilience, and inadequate information and accountability are important gaps preventing access to quality health services which often or mostly affect the vulnerable and disadvantaged the most.
(c) Valuable lessons learned on ensuring that no one is left behind;
- Clear political commitment: The Millennium Development Goals introduced new understanding of development and brought new approaches which shaped collaboration around their achievement at global, regional and national levels. They galvanized concerted action around a limited number of time-bound, measurable and easy-to-communicate goals.
- Measurement and accountability: The MDGs promoted measurement, and the development of monitoring systems, without which world would not be in a position to track progress with the degree of confidence that is now possible. The Commission on Information and Accountability, co-chaired by President Kikwete of Tanzania and Prime Minister Harper of Canada, and with Director General of WHO and Secretary General of ITU as vice-chairs, developed a framework to ensure the measurement of promised resources for women’s and children’s health. The established accountability framework identifies a core set of indicators for results and resources, proposes an action plan to improve health information systems, and explores opportunities to improve access to information through information technology
- Sustainable and predictable funding: The period of the Millennium Development Goals, 2000 to 2015, has also seen, particularly during the initial decade, significant increases in development financing, especially for health: development assistance for health more than tripled between 2000 and 2013, accompanied by strong growth in domestically sourced financing.
- Global norms translated into national-level action: WHO has initiated and coordinated development and adoption of global-level action plans and strategies and supported their country-level implementation. For example, In 2014, the Health Assembly in resolution WHA67.10 endorsed the Newborn health action plan, which provides a road map of strategic actions for preventing newborn mortality, and will also contribute to reducing maternal mortality and stillbirths. Subsequently, several countries have developed new or sharpened national plans for newborn health. Globally, a coordination mechanism has been put in place to advance country implementation, monitoring and evaluation, and advocacy
- Use of targeted programs to promote health system’s strengthening:
- In many countries, the introduction of new vaccines, such as rotavirus vaccine and pneumococcal vaccine, has been used as an opportunity for promoting a broader child health agenda, including for instance messaging on care seeking and treatment for pneumonia and diarrhoea, and the promotion of nutrition and safe water and sanitation interventions;
- National TB programmes’ work on addressing multidrug-resistant (MDR) and extensively drug-resistant (XDR) tuberculosis (TB), which is usually sign of inadequate clinical care or drug management, reinforced close collaboration with and strengthening of all health services;
- Rapid scaling up of antiretroviral therapy (ART) for HIV/AIDS, for example as part of the “3by5” initiative, supported integration of HIV/AIDS services into the public health systems, even down to primary health care facilities with limited resources in many countries and communities.
(d) Emerging issues likely to affect the realization of this principle;
Demographic trends fundamentally influence capacity of health systems in all countries. The Health in 2015: from MDGS, Millennium Development Goals, to SDGs, Sustainable Development Goals identifies the following population trends which will shape health response in the next 15 years:
- Fertility and population growth: Even as fertility rates are falling globally, population growth is slowing almost everywhere except in Africa. Populations are growing fast in many areas which are most vulnerable to climate change and may exacerbate water shortages and declining food yields. High fertility has important consequences for society as a whole and its development. In health, it means that global reproductive, maternal, newborn and child health will remain focused on Africa and Asia.
- The youth bulge: the report shows that the total number of young people is at an all-time high, with nearly 2.0 billion people between the ages of 10 and 24 projected by 2030. Investing in health in during adolescence can have critical benefits throughout the life course. For health systems, it requires extending the improvements in maternal and child health to adolescent, focus on health promotion and preventive measures, including dealing with mental disorders such as depression due to high rate of unemployment.
- Ageing: By 2030, 71% of older people will live in los- and middle-income countries. Countries in demographic transition require reorientation of the health sector to deal with NCDs, mental health disorders and injuries. Attention to the health of older people will require major shifts in the way health systems are designed – focus on primary prevention and managing declines in functioning.
- Migration: Many migrants do not have access to health care in countries of transit or destination. A comprehensive response to health of migrants include strengthening health systems; support coherent migrant-sensitive policies across sectors; developing social protection agreements; raising awareness and participatory approach between migrants themselves; as well as mobilize and coordinate partners’ support. When it comes to migration of health workers, the 2010 WHO Global Code of Practice on the International Recruitment of Health Personnel drew attention to the problem of richer countries recruiting from poorer nations with health workers shortages.
- Urbanization: Urban health inequalities are important concern. The new Global report on urban health: equitable, healthier cities for sustainable development show a number of health conditions and vulnerabilities that emerged offsetting earlier gains. Urban environments, urban life styles and high population density are favourable for rise in NCDs, fast spread of infectious diseases, increased risk for violence and injuries. At least 102 cities in 53 countries use the WHO’s Urban Health Equity Assessment and Response Tool (Urban HEART) to analyse and plan for more equitable health outcomes.
In addition, the report of the High-level Panel on the Global Response to Health Crises Protecting Humanity from Future Health Crises noted that the high risk of major health crises is widely underestimated, and that the world’s preparedness and capacity to respond is woefully insufficient. The Panel recognized the changing nature of today’s epidemics and its impact on countries beyond health systems. It has made twenty-seven recommendations for action at the national, regional and international levels, including many measures that cut across governance levels and require engagement with all sectors of society.
(e) Areas where political guidance by the high-level political forum is required
The high-level political forum could address several issues of importance to all SDGs and to the 2030 Agenda as “integral and indivisible” in its nature:
- Data gap: Significant data gaps will need to be filled in order to reliably track progress towards the SDGs. For example, an estimated 53% of deaths globally aren’t registered due to non-existance of systems to capture civil registration and vital statistics (CRVS);
- Integrated nature of the SDGs: The crucial importance of interlinkages needs to be stressed to ensure that the purpose of the new Agenda is realized. During the MDGs period, funding and political attention fuelled intense competition during the period of consultation and implementation with little concern for the coherence of the agenda as a whole;
- Country and regional follow-up and review processes are the basis for accountability and remedial actions.
(f) Policy recommendations on ways to accelerate progress for those at risk of being left behind
The organizations of the UN system have developed important normative instruments, ranging from international legal instruments, norms, standards, policy guidance, strategies, action plans in their respective field of expertise. However, the level of implementation at national level, even of those which have been integrated in national legislation, is neither consistent nor sufficient, in certain areas. The high-level political forum could mobilize global attention and support for identifying and addressing barriers at national level for their full and consistent implementation.
The high-level political forum could build upon and further promote lessons learned and good practices in some of the following areas:
- The adoption of the Sustainable Development Goals offers an opportunity to take a fresh look at the institutional arrangements, both in Member States and within the UN system, that are required to improve and maintain people’s health;
- The focus on measurement has encouraged political leaders in several countries to make public commitments to achieving specific targets in areas such as maternal or child mortality. These commitments not only put pressure on health ministries but also provide a way for civil society, parliaments and the media to hold health providers and governments at large accountable for their performance;
- The 2030 Agenda offers an opportunity to rationalize the reporting requirements contained in multiple resolutions of individual UN system organizations. For the health-related goals, many existing reporting systems can be used to monitor individual targets. The key risk, however, is that current efforts to develop indicators, assess progress and hold governments and others to account focus exclusively on individual targets, ignoring the big picture, the interrelations between Goals and targets and, particularly, equity;
- Accountability driven from global level can initiate and support national efforts. In 2015, in the fourth and final year of implementing the recommendations of the Commission on Information and Accountability for Women’s and Children’s Health, country-level action continued on key focus areas, with 17 countries moving to a second round of targeted funding. Of the 75 focus countries, 68 have national accountability frameworks being implemented through catalytic funds supporting the Commission’s recommendations; 55 have implemented facility-based maternal death reviews and 30 have implemented community-based maternal death reviews; 33 countries have completed at least one year of national health accounts; civil society, parliaments and media from 21 countries are engaged in budget tracking; and parliaments in 30 countries have taken legislative action for women and children, including increased budget allocations
- The intensity of focus (and investment) has been a key driver of innovation, enabling the scale-up of new interventions, such as antiretroviral therapy, long-lasting insecticide-treated bednets, artemisinin-based combination therapy, vaccines against pneumonia and diarrhoeal disease, and new and better diagnostic tests for multiple diseases