DOI: 10.1111/1471-0528.13023
Commentary
www.bjog.org
Women’s health beyond 2015: challenges and opportunities for global health governance T Pang Lee Kuan Yew School of Public Policy, National University of Singapore, Singapore, Singapore Correspondence: T Pang, Lee Kuan Yew Shool of Public Policy, National University of Singapore, 469C Bukit Timah Rd, Singapore 259772, Singapore. Email [email protected] Accepted 2 July 2014. Published Online 4 August 2014.
Please cite this paper as: Pang T. Women’s health beyond 2015: challenges and opportunities for global health governance. BJOG 2015;122:149–151.
The clock is ticking, with the 2015 deadline for the achievement of the Millennium Development Goals (MDGs) fast approaching. With the impending adoption of the post-2015 sustainable development agenda,1,2 there are widespread concerns within the health community that both the goals and the resources needed to fully achieve the MDG objectives may fall by the wayside. There has been talk that ‘health has had its day’ and that it is now the turn of other sectors to take front stage and benefit from the next global compact to improve human existence. Although some of these fears have recently been assuaged, some of the concerns are justified in the context of women’s health. At the same time, opportunities and research windows are appearing on the horizon, which provides some grounds for optimism for the future. However, for optimism to turn into sustainable and continued support for women’s health, collective action is required. The action should be based on defining international priorities and has to be underpinned by effective and inclusive governance of global health in the context of the post-2015 development agenda. Good progress has been made in achieving Millennium Development Goals (MDG) 4 and 5 to reduce child mortality and improve maternal health. The global maternal mortality ratio has declined from 400 maternal deaths per 100 000 live births to 210 between 1990 and 2010. However, progress seems to be falling short of the target, especially in parts of South Asia and sub-Saharan Africa, and only 16 countries are estimated to achieve the MDG 5 target for maternal mortality by 2015.3 In addition, in the developing world nearly 50 million babies are delivered annually without skilled care, only half of women receive the recommended amount of care, and adolescent pregnancies remain at very high levels.4 Other areas continue to need attention, such as sexual
ª 2014 Royal College of Obstetricians and Gynaecologists
and reproductive health, abortion, non-communicable diseases, ageing, violence and injuries. Female genital mutilation remains a serious concern in many developing countries. Much more still needs to be done and in spite of a clear need to sustain efforts to improve women’s health, worrying signs have appeared recently. The United Nations (UN) Secretary General’s flagship initiative, ‘Every Woman, Every Child’, launched in 2010, is under threat.5 No pledges of support have been made for 2015 and the possibility of ‘donor fatigue’ among the major supporters of the initiative (Canada, Germany, Norway, Sweden, UK, USA) was raised. Without urgent funding, the World Health Organization (WHO) will not be able to continue activities of the initiative beyond July 2014.5 ‘If this result came to pass, one of the most important recent catalysts to accelerate reductions in maternal, newborn and child mortality will cease to exist’.5 It would be a great shame if this were to happen. Recent research has built a strong, compelling and persuasive case for continued support and commitment for efforts to improve women’s and children’s health. The Global Investment Framework for Women’s and Children’s Health6 estimated the potential health and socioeconomic returns of six investment ‘packages’ including maternal and newborn health, child health, immunisation, family planning, HIV/ AIDS and malaria, with nutrition as a cross-cutting theme. Increasing expenditure on these packages by just $5 per person per year up to 2035 in 74 high-burden countries has the potential to give a nine-fold return of that value in economic and social benefits. In addition to greater economic growth through improved productivity, the returns also include preventing the needless deaths of 147 million children, 32 million stillbirths, and 5 million women by 2035. The authors state that ‘these gains could be achieved
149
Pang
by an additional investment of $30 billion per year, equivalent to a 2% increase above current spending’.6 Apart from the main international priorities in women’s and children’s health, and multiple global initiatives to support them,3 the relevance and importance of science for the future of global women’s health should also be emphasised, as knowledge is the foundation of future progress. In this regard, several key research priorities are worth mentioning. First, more needs to be done to promote the inclusion of women and minorities in health research to strengthen further the knowledge base in women’s health.7 As women and men have different risks for many diseases, it is important to integrate sex-specific analysis in all aspects of research, from basic to clinical research, as well as in subsequent implementation and operational research into strengthening health service delivery. In a landmark announcement, the US National Institutes of Health recently announced new policies to ensure that preclinical research funded by the agency considers both females and males.8 Secondly, and especially in the context of developing countries, strengthening research capacity remains a very important priority. WHO’s UNDP/UNFPA/UNICEF/WHO/ World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP) has played an important leadership role for the past 40 years and is currently building a novel collaborative international research and research capacity strengthening platform. In addition to the WHO, other key UN agencies such as UNFPA and UNICEF must continue to play leading roles. Thirdly, in the context of universal health coverage (UHC) and the need to strengthen health systems through health systems research, ‘effective and affordable health interventions and technologies will fail to substantially improve health outcomes for women in developing countries unless health systems within these countries can deliver appropriate health services that meet women’s specific needs’.9 In the post-2015 agenda, UHC has been incorporated as a key instrument in achieving health outcomes10 and it is important that the relevant interventions and technologies be fully integrated within the UHC and health systems frameworks. This dimension is especially important for non-communicable diseases, which require longer-term care and can impose huge burdens on fragile health systems. Fourthly, research must play a central role in broadening the remit and scope for women’s health so that women are ‘able to fulfil their potential in their personal, family, and community life, and in wider society’.11 In particular, continuing inequalities which place women at a disadvantage continue to persist in various health, societal and workplace settings and must be addressed through innovative multi-disciplinary and multi-sectoral research.
150
Hopefully this will result in a different culture which treats women and men equally.11 What is needed in the future to maintain the momentum, visibility and support for women’s health and women’s health research? Foremost is the need for effective, inclusive and sustainable global governance to finance, implement and harmonise initiatives. Good governance is extremely important to achieve four major goals of coordination, context, strategy and human rights.
Coordination The existence of many laudable but often diverse initiatives will require effective coordination and, importantly, the need to build on previous gains made in the past decade. The Millennium Development Goals; Every Woman, Every Child; Safe Motherhood Initiatives; The Commission on Information and Accountability for Women’s and Children’s Health; The Pink Ribbon campaign; campaigns to stop female genital mutilation; and myriad others have done much in the past decade to ensure that women’s health is high on many countries’ agendas. Leadership at the highest levels of the UN is also necessary for effective coordination, harmonisation and synergies to succeed in the future. In addition to the UN agencies, a far more inclusive approach to governance is also needed that involves civil society, NGOs, the private sector, academia, researchers and public health agencies, as well as development partners, donors, funds and foundations.
Context Global governance must serve to guide and place women’s health within the context of the post-2015 sustainable development agenda. The MDGs were able to focus the global agenda and resources on specific health challenges (e.g. infectious diseases, maternal and child health), but the post-2015 agenda is a broader, more ambitious agenda which will require coordination, goodwill and political commitment across multiple sectors. The post-2015 agenda seeks to integrate economic development (including poverty elimination), social inclusion, environmental sustainability, and good governance into a combined sustainable development agenda.10 The process to define the Sustainable Development Goals (SDGs) so far has identified three targets: ‘accelerating progress on the health MDG agenda’; ‘reducing the burden of major non-communicable diseases’ (NCDs); and ‘ensuring universal health coverage and access’. Encouragingly, the achievement of the MDGs, after some reconfiguration, remains a priority. ‘Universal sexual and reproductive health and rights’ has also gained prominence as a target of the agenda.9 UHC has been incorporated, not as a target, but as instrumental in achieving health outcomes.
ª 2014 Royal College of Obstetricians and Gynaecologists
Women’s health beyond 2015
Strategy Based on an appreciation of the appropriate context, the right strategy needs to be developed. Hill et al.10 have argued that four strategic ‘shifts’ are needed in the post-2015 era: “reframe health from the poverty reduction focus of the MDGs to embrace the social sustainability paradigm that underpins the new goals; health advocates need to speak and listen to the whole sustainable development agenda, and assert health in every theme and every relevant policy; the need to construct goals that will be truly ‘universal’, that will engage every nation – a significant re-orientation from the focus on low-income countries of the MDGs; and health advocates need to explore what global governance structures will be needed to finance and implement these universal Sustainable Development Goals (SDGs).”
Disclosure of interests None.
Contributions to authorship Sole author.
Details of ethics approval Ethics approval not required.
Funding None.
Acknowledgement I would like to thank Dr Julia Hussein for the invitation to write this commentary. &
References Governance Finally, this leads us to the central question: Is the current state of global governance up to delivering the above goals? In the view of some, a paradigm shift in global health governance is needed to achieve this objective. For example, The Lancet-University of Oslo Commission on Global Health Governance for Health12 calls for stronger crossand multi-sectoral global action for health through a Multi stakeholder Platform on Governance for Health, with strong leadership from the highest levels of the UN. Such a platform would ‘serve as a policy forum to provide space for diverse stakeholders to frame issues, set agendas, examine and debate policies in the making that would have an effect on health and health equity, and identify barriers and propose solutions for concrete policy processes’.11 The Commission also calls for the ‘independent monitoring of how global governance processes affect health equity to be institutionalised through an Independent Scientific Monitoring Panel and mandated health equity impact assessments within international organisations’.12 Beyond these strategic actions, good governance must also incorporate a human rights approach to women’s health which includes accountability, participation, ownership, transparency, equity and non-discrimination. Much more needs to be done to build on achievements of the past decade in order to ensure that women’s health becomes an integral part of the core of the post-2015 sustainable development agenda. It is important that the various issues and factors raised above be taken into consideration in continuing international negotiations to ensure the rightful place of ‘every woman, every child’ in future global agendas.
ª 2014 Royal College of Obstetricians and Gynaecologists
1 United Nations. A New Global Partnership: Eradicate Poverty and Transform Economies Through Sustainable Development. The Report of the High-Level Panel of Eminent Persons on the Post-2015 Development Agenda. New York: United Nations, 2013. 2 Global Thematic Consultation on Health. Health in the Post-2015 Agenda. Report of the Global Thematic Consultation on Health. New York: The World We Want, 2013. 3 Kassebaum NJ, Bertozzi-Villa A, Coggeshall MS, Shackelford KA, Steiner C, Heuton KR, et al. Global, regional, and national levels and causes of maternal mortality during 1990–2013: a systematic analysis for the Global Burden of Diseases Study 2013. Lancet 2014. doi: 10.1016/S0140-6736(14)60696-6. 4 United Nations. The Millennium Development Goals Report 2013. New York: United Nations, 2013. 5 Horton R. Offline: Ban Ki Moon’s global health initiative in jeopardy. Lancet 2014;382:292. 6 Stenberg K, Axelson H, Sheehan P, Anderson I, Gulmezoglu AM, Temmerman M, et al. Advancing social and economic development by investing in women’s and children’s health: a new global investment framework. Lancet 2014;383:1333–54. 7 Sex-Specific Medical Research: Why Women’s Health Can’t Wait. Boston, MA: Mary Horrigan Connors Center for Women’s Health and Gender Biology, 2014. www.brighamandwomens.org/Departments_ and_Services/womenshealth/ConnorsCenter/Policy/ConnorsReport FINAL.pdf. 8 Clayton JA, Collins FS. NIH to balance sex in cell and animal studies. Nature 2014;509:282–3. 9 Samb B. Reforming country health systems for women’s health. Lancet 2010;375:354–5. 10 Hill PS, Buse K, Brolan CE, Ooms G. How can health remain central post-2015 in a sustainable development paradigm? Global Health 2014;10:18. 11 The Lancet. Women’s health – broadening the remit. Lancet 2013;381:777. 12 Ottersen OP, Dasgupta J, Blouin C, Buss P, Chongsuvivatwong V, Frenk J, et al. The Lancet-University of Oslo Commission on Global Governance for Health. The political origins of health inequity: prospects for change. Lancet 2014;383:630–7.
151
Copyright of BJOG: An International Journal of Obstetrics & Gynaecology is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Commentary
www.bjog.org
Women’s health beyond 2015: challenges and opportunities for global health governance T Pang Lee Kuan Yew School of Public Policy, National University of Singapore, Singapore, Singapore Correspondence: T Pang, Lee Kuan Yew Shool of Public Policy, National University of Singapore, 469C Bukit Timah Rd, Singapore 259772, Singapore. Email [email protected] Accepted 2 July 2014. Published Online 4 August 2014.
Please cite this paper as: Pang T. Women’s health beyond 2015: challenges and opportunities for global health governance. BJOG 2015;122:149–151.
The clock is ticking, with the 2015 deadline for the achievement of the Millennium Development Goals (MDGs) fast approaching. With the impending adoption of the post-2015 sustainable development agenda,1,2 there are widespread concerns within the health community that both the goals and the resources needed to fully achieve the MDG objectives may fall by the wayside. There has been talk that ‘health has had its day’ and that it is now the turn of other sectors to take front stage and benefit from the next global compact to improve human existence. Although some of these fears have recently been assuaged, some of the concerns are justified in the context of women’s health. At the same time, opportunities and research windows are appearing on the horizon, which provides some grounds for optimism for the future. However, for optimism to turn into sustainable and continued support for women’s health, collective action is required. The action should be based on defining international priorities and has to be underpinned by effective and inclusive governance of global health in the context of the post-2015 development agenda. Good progress has been made in achieving Millennium Development Goals (MDG) 4 and 5 to reduce child mortality and improve maternal health. The global maternal mortality ratio has declined from 400 maternal deaths per 100 000 live births to 210 between 1990 and 2010. However, progress seems to be falling short of the target, especially in parts of South Asia and sub-Saharan Africa, and only 16 countries are estimated to achieve the MDG 5 target for maternal mortality by 2015.3 In addition, in the developing world nearly 50 million babies are delivered annually without skilled care, only half of women receive the recommended amount of care, and adolescent pregnancies remain at very high levels.4 Other areas continue to need attention, such as sexual
ª 2014 Royal College of Obstetricians and Gynaecologists
and reproductive health, abortion, non-communicable diseases, ageing, violence and injuries. Female genital mutilation remains a serious concern in many developing countries. Much more still needs to be done and in spite of a clear need to sustain efforts to improve women’s health, worrying signs have appeared recently. The United Nations (UN) Secretary General’s flagship initiative, ‘Every Woman, Every Child’, launched in 2010, is under threat.5 No pledges of support have been made for 2015 and the possibility of ‘donor fatigue’ among the major supporters of the initiative (Canada, Germany, Norway, Sweden, UK, USA) was raised. Without urgent funding, the World Health Organization (WHO) will not be able to continue activities of the initiative beyond July 2014.5 ‘If this result came to pass, one of the most important recent catalysts to accelerate reductions in maternal, newborn and child mortality will cease to exist’.5 It would be a great shame if this were to happen. Recent research has built a strong, compelling and persuasive case for continued support and commitment for efforts to improve women’s and children’s health. The Global Investment Framework for Women’s and Children’s Health6 estimated the potential health and socioeconomic returns of six investment ‘packages’ including maternal and newborn health, child health, immunisation, family planning, HIV/ AIDS and malaria, with nutrition as a cross-cutting theme. Increasing expenditure on these packages by just $5 per person per year up to 2035 in 74 high-burden countries has the potential to give a nine-fold return of that value in economic and social benefits. In addition to greater economic growth through improved productivity, the returns also include preventing the needless deaths of 147 million children, 32 million stillbirths, and 5 million women by 2035. The authors state that ‘these gains could be achieved
149
Pang
by an additional investment of $30 billion per year, equivalent to a 2% increase above current spending’.6 Apart from the main international priorities in women’s and children’s health, and multiple global initiatives to support them,3 the relevance and importance of science for the future of global women’s health should also be emphasised, as knowledge is the foundation of future progress. In this regard, several key research priorities are worth mentioning. First, more needs to be done to promote the inclusion of women and minorities in health research to strengthen further the knowledge base in women’s health.7 As women and men have different risks for many diseases, it is important to integrate sex-specific analysis in all aspects of research, from basic to clinical research, as well as in subsequent implementation and operational research into strengthening health service delivery. In a landmark announcement, the US National Institutes of Health recently announced new policies to ensure that preclinical research funded by the agency considers both females and males.8 Secondly, and especially in the context of developing countries, strengthening research capacity remains a very important priority. WHO’s UNDP/UNFPA/UNICEF/WHO/ World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP) has played an important leadership role for the past 40 years and is currently building a novel collaborative international research and research capacity strengthening platform. In addition to the WHO, other key UN agencies such as UNFPA and UNICEF must continue to play leading roles. Thirdly, in the context of universal health coverage (UHC) and the need to strengthen health systems through health systems research, ‘effective and affordable health interventions and technologies will fail to substantially improve health outcomes for women in developing countries unless health systems within these countries can deliver appropriate health services that meet women’s specific needs’.9 In the post-2015 agenda, UHC has been incorporated as a key instrument in achieving health outcomes10 and it is important that the relevant interventions and technologies be fully integrated within the UHC and health systems frameworks. This dimension is especially important for non-communicable diseases, which require longer-term care and can impose huge burdens on fragile health systems. Fourthly, research must play a central role in broadening the remit and scope for women’s health so that women are ‘able to fulfil their potential in their personal, family, and community life, and in wider society’.11 In particular, continuing inequalities which place women at a disadvantage continue to persist in various health, societal and workplace settings and must be addressed through innovative multi-disciplinary and multi-sectoral research.
150
Hopefully this will result in a different culture which treats women and men equally.11 What is needed in the future to maintain the momentum, visibility and support for women’s health and women’s health research? Foremost is the need for effective, inclusive and sustainable global governance to finance, implement and harmonise initiatives. Good governance is extremely important to achieve four major goals of coordination, context, strategy and human rights.
Coordination The existence of many laudable but often diverse initiatives will require effective coordination and, importantly, the need to build on previous gains made in the past decade. The Millennium Development Goals; Every Woman, Every Child; Safe Motherhood Initiatives; The Commission on Information and Accountability for Women’s and Children’s Health; The Pink Ribbon campaign; campaigns to stop female genital mutilation; and myriad others have done much in the past decade to ensure that women’s health is high on many countries’ agendas. Leadership at the highest levels of the UN is also necessary for effective coordination, harmonisation and synergies to succeed in the future. In addition to the UN agencies, a far more inclusive approach to governance is also needed that involves civil society, NGOs, the private sector, academia, researchers and public health agencies, as well as development partners, donors, funds and foundations.
Context Global governance must serve to guide and place women’s health within the context of the post-2015 sustainable development agenda. The MDGs were able to focus the global agenda and resources on specific health challenges (e.g. infectious diseases, maternal and child health), but the post-2015 agenda is a broader, more ambitious agenda which will require coordination, goodwill and political commitment across multiple sectors. The post-2015 agenda seeks to integrate economic development (including poverty elimination), social inclusion, environmental sustainability, and good governance into a combined sustainable development agenda.10 The process to define the Sustainable Development Goals (SDGs) so far has identified three targets: ‘accelerating progress on the health MDG agenda’; ‘reducing the burden of major non-communicable diseases’ (NCDs); and ‘ensuring universal health coverage and access’. Encouragingly, the achievement of the MDGs, after some reconfiguration, remains a priority. ‘Universal sexual and reproductive health and rights’ has also gained prominence as a target of the agenda.9 UHC has been incorporated, not as a target, but as instrumental in achieving health outcomes.
ª 2014 Royal College of Obstetricians and Gynaecologists
Women’s health beyond 2015
Strategy Based on an appreciation of the appropriate context, the right strategy needs to be developed. Hill et al.10 have argued that four strategic ‘shifts’ are needed in the post-2015 era: “reframe health from the poverty reduction focus of the MDGs to embrace the social sustainability paradigm that underpins the new goals; health advocates need to speak and listen to the whole sustainable development agenda, and assert health in every theme and every relevant policy; the need to construct goals that will be truly ‘universal’, that will engage every nation – a significant re-orientation from the focus on low-income countries of the MDGs; and health advocates need to explore what global governance structures will be needed to finance and implement these universal Sustainable Development Goals (SDGs).”
Disclosure of interests None.
Contributions to authorship Sole author.
Details of ethics approval Ethics approval not required.
Funding None.
Acknowledgement I would like to thank Dr Julia Hussein for the invitation to write this commentary. &
References Governance Finally, this leads us to the central question: Is the current state of global governance up to delivering the above goals? In the view of some, a paradigm shift in global health governance is needed to achieve this objective. For example, The Lancet-University of Oslo Commission on Global Health Governance for Health12 calls for stronger crossand multi-sectoral global action for health through a Multi stakeholder Platform on Governance for Health, with strong leadership from the highest levels of the UN. Such a platform would ‘serve as a policy forum to provide space for diverse stakeholders to frame issues, set agendas, examine and debate policies in the making that would have an effect on health and health equity, and identify barriers and propose solutions for concrete policy processes’.11 The Commission also calls for the ‘independent monitoring of how global governance processes affect health equity to be institutionalised through an Independent Scientific Monitoring Panel and mandated health equity impact assessments within international organisations’.12 Beyond these strategic actions, good governance must also incorporate a human rights approach to women’s health which includes accountability, participation, ownership, transparency, equity and non-discrimination. Much more needs to be done to build on achievements of the past decade in order to ensure that women’s health becomes an integral part of the core of the post-2015 sustainable development agenda. It is important that the various issues and factors raised above be taken into consideration in continuing international negotiations to ensure the rightful place of ‘every woman, every child’ in future global agendas.
ª 2014 Royal College of Obstetricians and Gynaecologists
1 United Nations. A New Global Partnership: Eradicate Poverty and Transform Economies Through Sustainable Development. The Report of the High-Level Panel of Eminent Persons on the Post-2015 Development Agenda. New York: United Nations, 2013. 2 Global Thematic Consultation on Health. Health in the Post-2015 Agenda. Report of the Global Thematic Consultation on Health. New York: The World We Want, 2013. 3 Kassebaum NJ, Bertozzi-Villa A, Coggeshall MS, Shackelford KA, Steiner C, Heuton KR, et al. Global, regional, and national levels and causes of maternal mortality during 1990–2013: a systematic analysis for the Global Burden of Diseases Study 2013. Lancet 2014. doi: 10.1016/S0140-6736(14)60696-6. 4 United Nations. The Millennium Development Goals Report 2013. New York: United Nations, 2013. 5 Horton R. Offline: Ban Ki Moon’s global health initiative in jeopardy. Lancet 2014;382:292. 6 Stenberg K, Axelson H, Sheehan P, Anderson I, Gulmezoglu AM, Temmerman M, et al. Advancing social and economic development by investing in women’s and children’s health: a new global investment framework. Lancet 2014;383:1333–54. 7 Sex-Specific Medical Research: Why Women’s Health Can’t Wait. Boston, MA: Mary Horrigan Connors Center for Women’s Health and Gender Biology, 2014. www.brighamandwomens.org/Departments_ and_Services/womenshealth/ConnorsCenter/Policy/ConnorsReport FINAL.pdf. 8 Clayton JA, Collins FS. NIH to balance sex in cell and animal studies. Nature 2014;509:282–3. 9 Samb B. Reforming country health systems for women’s health. Lancet 2010;375:354–5. 10 Hill PS, Buse K, Brolan CE, Ooms G. How can health remain central post-2015 in a sustainable development paradigm? Global Health 2014;10:18. 11 The Lancet. Women’s health – broadening the remit. Lancet 2013;381:777. 12 Ottersen OP, Dasgupta J, Blouin C, Buss P, Chongsuvivatwong V, Frenk J, et al. The Lancet-University of Oslo Commission on Global Governance for Health. The political origins of health inequity: prospects for change. Lancet 2014;383:630–7.
151
Copyright of BJOG: An International Journal of Obstetrics & Gynaecology is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
