For the past several months, West Africa has been plagued by an unprecedented Ebola epidemic, which continues to grow and is quickly becoming an international health threat. We know how to stop the virus, the challenge is to strengthen the current system. Fortifying the global health system will be difficult - mobilizing the international community through financial and technical assistance, educating populations and other public health efforts are all needed to curb the epidemic.
The Government of Senegal is committed to the principle of Universal Health Coverage (UHC) and providing essential basic health services to its citizenry. Through the leadership of the Senegal Ministry of Health, we have spent the past couple of years performing important research and planning designed to help the nation scale services with the goal of eventually reaching UHC. This work has included not only ramping up the services the government provides, but also improving the planning, administration and monitoring of the specific health interventions we implement so that we are constantly adapting and improving. This includes providing a free essential health services to all children, providing women and elders with a set of health services at no cost and improving the ability of our health insurance organizations and community based health service providers to help realize our dream of universal health coverage for all Senegalese citizens.
For the past several months, West A
Women and children – key to Global Health Security
- Dr Flavia Bustreo, Assistant Director-General, Family, Women’s and Children’s Health, World Health Organization
- HRH Princess Sarah Zeid, Global Maternal and Newborn Health advocate
- Dr Jane Thomason, Chief Executive Officer, Abt JTA CEO
Women and children bear the greatest burden and risk of health insecurity and require increased attention, particularly in crisis and fragile situations. As the community comes together to develop a new Global Strategy for Women’s, Children’s and Adolescents’ Health, we must ensure that global health security is central to this agenda. The benefits of investing in health globally have never been more obvious. The recent Ebola outbreak dramatically highlighted the risks to growth and stability of the concerned countries, and the consequences of poor health systems in this globalised world. Such outbreaks or systemic shocks can undermine economic and social stability and decimate health systems in low-income and fragile states. The World Bank Group’s analysis1 of the economic impacts of the outbreak on the three hardest-hit countries (Guinea, Liberia and Sierra Leone) reported that GDP growth estimates for 2014 have been revised sharply downward compared to pre-crisis estimates. The report also found that the total fiscal impact was more than one-half billion dollars in that same year. Eradicating the epidemic in countries directly affected is a primary concern, but avoiding the strong economic consequences also requires investment in preparedness in neighbouring countries. Global health security is inextricably linked to public security, including links with bioterrorism, and cross-border health risks such as the transmission of anti-microbial resistant organisms, and health risks associated with non-communicable diseases, environmental degradation and conflict.
For women’s and children’s health, significant progress was achieved between 1990 and 2013, with rates of global maternal mortality2 having dropped by 45 percent and under-five mortality by 49 percent3. But the global figures hide stark differences between and within countries and mask the unfinished agenda. It is clear that the majority of low- and middle-income countries will not achieve MDGs 4 and 5, and 222 million women still do not have adequate access to contraception4. The worst rates of preventable mortality and morbidity among women, adolescents and children occur in humanitarian settings, with 60 percent of preventable maternal deaths and 53 percent of under-five deaths taking place in settings of conflict, displacement and natural disasters5.
Women, particularly those living below the poverty line, are often locked into a cycle of ill health exacerbated by child-bearing, hard physical labour and difficult access to food and resources. These women are more likely to conceive too young; have a greater number of closely spaced pregnancies; have a higher risk of malaria, diabetes, anaemia and other conditions during pregnancy; have complications due to poor nutrition; give birth without assistance and risk unsafe terminations.
Poverty contributes to ill health by increasing exposure to risk factors for infection and chronic disease, and by lowering access to simple inexpensive preventive measures such as clean and adequate quantities of water, soap and insecticide-treated bednets. Ill health in turn contributes to poverty by reducing capacity for employment and education, and draining household resources to meet the costs of health care.
High levels of mortality and morbidity compromises countries’ ability to ensure internal and external stability and security. The AIDS pandemic, for example, created a security issue particularly in southern Africa, where rates are highest. The disease has produced a generation of orphans who, lacking social, financial and emotional resources, become an at-risk population falling into a cycle of ill-health and poverty, with a related increase in crime rates.
There is no health security in situations of conflict
Conflict is the champion of poverty; it weakens the health of populations through violence, including sexual violence, injury, trauma, as well as through overcrowding, malnourishment, exposure, contamination, epidemic diseases, and lack of access to medical care, including maternal care. Conflict-related damage to infrastructure further increases the risk of disease and death. In conflict situations, water supplies may be cut off or made unsafe for consumption; electricity supplies can become intermittent or nonexistent; sanitation systems collapse; food is often contaminated; and rubble becomes a breeding ground for rats and mosquitos. In these conditions, disease inevitably spreads and mortality starts to rise. Refugees and internally displaced populations are particularly vulnerable.
Women and children living in the world’s 51 fragile states suffer disproportionately from the various threats to human peace and security, particularly in early childhood and reproductive years6. Women and girls are targets of rape and sexual violence, a tool often used during conflict to achieve military or political objectives—with long-lasting health, social and economic consequences7. Children similarly bear the brunt of conflict and violent social change; they may be uprooted from their homes, schools, friends, and family members, may be maimed and injured, and sometimes forced to take an active part in hostilities. Many conflicts can last for years, meaning that children can grow up never knowing peace and stability8. The emotional scars and mental trauma of conflict are a destructive, generation-impacting legacy.
There is no health security where there is no identity
The world struggles to even identify the poorest and most vulnerable populations, let alone reach them. Every year, 230 million children under-five years of age are never officially registered. And every year, two thirds of all deaths are neither registered nor medically certified9. The right to recognition as a person before the law is conferred by birth registration; unregistered individuals have limited or no access to services, or to the rights to which they are entitled, and may be vulnerable to statelessness and the associated lack of protection. This is especially critical for displaced populations in humanitarian settings.
As the global numbers of maternal and child deaths decline, it becomes increasingly important to identify and track the most marginalized and impoverished populations where mortality is highest. This requires improving country systems to reliably track and measure births, deaths and causes of death. Improved measurement through civil registration and vital statistics will greatly enhance each country’s ability to monitor aid, track mortality trends and lives saved, protect human rights, and ultimately protect vulnerable populations10.
New UN Secretary-General’s Global Strategy for Women’s, Children’s and Adolescents’ Health
To ensure that the world pays attention to the most impoverished, marginalized and conflict-affected communities, it is time to renew the Global Strategy for Women’s and Children’s Health launched by UN Secretary-General Ban Ki-moon in 2010. The new Strategy will cover the period from 2016 – 2030, aligning with the UN Sustainable Development Goals and responding to the environment and challenges facing the post-2015 world. It will increase its focus on adolescent health, recognizing that adolescents are the adults of tomorrow, and many are already the parents of today. Adolescents face particular challenges; the biggest causes of death in this age group are road accidents, HIV/AIDS, and self-harm11.
The new Strategy will set the foundation for continued improvements in women’s and children’s health by supporting the scale-up of the most successful health and social interventions. It will also strengthen progress towards health security and sustainability by strengthening linkages with other sectors including education, water and sanitation and nutrition.
In the aftermath of conflict, women play an essential role in rebuilding their nations12. Given the disproportionate burden carried by women and children in conflict and humanitarian settings, the new Strategy will be calibrated to address the complex challenges of these settings. This need was also clearly articulated in the recent Abu Dhabi Declaration,13 in which development and humanitarian experts urgently called on the global community to find better ways to address reproductive, maternal, newborn, child and adolescent health and wellbeing in humanitarian and fragile contexts.
The updated Global Strategy will build on the successes and lessons of the current Strategy, and look to tackle remaining challenges, such as increasing cooperation and integration of humanitarian and development activities, as set out in the Abu Dhabi Declaration. Key themes in the updated Strategy include the following:
- Encourage, strengthen and empower community participation: Women and young people are the first responders to crises and the leading innovators of sustainable solutions in crisis. They should be regarded as essential partners in preparedness, response and recovery.
- Strengthen and promote country leadership: The strategy will be led by national plans and priorities, and supported by multi-stakeholder partner alignment, to reduce fragmentation of efforts and financing mechanisms; and implementation of special projects and initiatives. The role of parliamentarians and civil society is critical, and needs to be further strengthened.
- Ensure harmonization and alignment: In the rush to attain the Millennium Development Goals, there has been a proliferation of well-meaning but uncoordinated efforts to advance women’s and children’s health. At every level, these efforts need to be aligned in a harmonized way under the renewed Global Strategy to find efficiencies and reduce the burden on countries.
- Uphold and expand multi-stakeholder partnerships: These have been effective - particularly around efforts to strengthen civil registration and vital statistics and to implement maternal death surveillance and response - and must continue under the renewed Strategy. This includes the engagement of all stakeholders including sectors other than health, government, parliamentarians, multilateral agencies, donors and foundations, civil society, the private sector, youth and media to create platforms for transformative change.
- Establish a financing mechanism that respond to the needs of women and children in the most difficult settings: The World Bank, WHO and the Governments of Norway, Canada, and the United States have announced the creation of a Global Financing Facility to help meet the financing requirements of the Global Strategy. This will clearly have to be supplemented by mobilizing donor, domestic and new forms of finance to meet the needs of the most vulnerable.
- Root accountability in affected communities: Implementation of the current Strategy shows the increasing prominence and added value of creating an accountability framework around women’s and children’s health. This has included existing national accountability processes, an independent review component, and harmonization of accountability initiatives. These mechanisms will be essential to measure progress and keep all partners accountable in the post-2015 period, and additional efforts must be made to ensure that accountability for results in humanitarian and fragile settings is grounded with affected communities.
Despite the improvements in health indicators in many countries, the first Global Strategy for Women’s and Children’s Health did not sufficiently address the role played by insecurity, humanitarian and crisis contexts in driving health outcomes. The health of women and children is a critical component to economic development. Yet, these populations carry a disproportionate burden of poverty, conflict and violence, and often lack such basic human rights as recognition before the law.
Accelerating progress towards improving the health of women and children is imperative. Scaling up successful high-impact interventions, and channeling new innovative tools, treatments and technologies to hard-to-reach populations are global challenges. Global health security will only be enhanced with new approaches to protecting the health of women and children in general, and in poverty and conflict in particular.
As discussions of the post-2015 development agenda continue, leading economists have expressed concern about the deep structural crisis of rising social inequality and the dangers of seeing more and more of the world’s wealth and opportunities concentrated in a shrinking number of privileged hands. I agree. I also regard universal health coverage as one of the most powerful social equalizers among all policy options. Countries such as Japan, which introduced universal health coverage in 1961 under a struggling economy, did so in a deliberate effort to promote social cohesion and boost growth of the middle classes as the backbone of a democratic society.
In just the past three years, the World Health Organization (WHO) has been approached by more than 80 countries seeking technical support in moving their health systems towards universal coverage. This trend gives me cause for great optimism: governments value a fair society where everyone has access to essential health care, no one is left behind, and no one pays for health with financial ruin.
I can remember the moment when I decided to take up the cause of campaigning against early and forced marriages. Shortly after I was appointed Canada’s Foreign Minister back in 2011, I travelled to Perth, Australia to take part in the Commonwealth Heads of Government meeting with Prime Minister Stephen Harper.
As the world focuses on the post-2015 development agenda, we must continue to look for ways to improve financing for health. As a global health community, we have made significant progress during the past 15 years and it would be a shame to allow a reversal of this progress because of a lack of adequate funds. This will require an unprecedented level of cooperation and collaboration between donor, recipient nations, the private sector and global health implementers.
Since I was elected president, we have been busy implementing important reforms for the people of Senegal. We have made tremendous progress in improving the democratic process, eliminating fraud and corruption and have worked with our African allies to improve accountability and transparency in investments and governance. Senegal, like many African countries, continues to benefit from these reforms as we grow economically, focus on building our infrastructure and continue to invest in health care for our people. However, many challenges—particularly in maternal and child health and nutrition—remain.
Upon assuming office in 2007, I promised the people of Sierra Leone and the rest of the world that my administration will create an open and progressive society that will improve the lives of every Sierra Leonean through ideas and action. My promise was not limited to transparency and open government, but included a vow to improve healthcare in Sierra Leone. Maternal and child health morbidity and mortality needed to improve significantly as rates reached 875 per 100,000 and 140 per 1000 respectively. As a country emerging from the ashes of war, moving from emergency and recovery towards sustainable development and prosperity, I believe that it is imperative to invest in the healthcare system and create robust capacity that is responsive to quality, timely and equitable health service delivery for all Sierra Leoneans.
With less than 1000 days remaining until 2015, our continued joint effort is needed more than ever to meet the UN Millennium Development Goals (MDGs). Over the last few years, we have seen promising global and national mobilisation for the MDGs that were lagging furthest behind: reducing child mortality and improving maternal health. Investing in life-saving commodities and family planning is value for money for every nation, and for its women, children and families. The Global Business Coalition Health, the World Health Assembly and the Women Deliver Conference are important arenas for key actors who are putting life-saving medicines and commodities on the agenda.