Mariam Claeson

Women and Health: the key for sustainable development

Executive summary Girls’ and women’s health is in transition and, although some aspects of it have improved substantially in the past few decades, there are still important unmet needs. Population ageing and transformations in the social determinants of health have increased the coexistence of disease burdens related to reproductive health, nutrition, and infections, and the emerging epidemic of chronic and non-communicable diseases (NCDs). Simultaneously, worldwide priorities in women’s health have themselves been changing from a narrow focus on maternal and child health to the broader framework of sexual and reproductive health and to the encompassing concept of women’s health, which is founded on a life-course approach. This expanded vision incorporates health challenges that aff ect women beyond their reproductive years and those that they share with men, but with manifestations and results that aff ect women disproportionally owing to biological, gender, and other social determinants. The complexity of the challenges faced by women throughout the life course needs an increased focus on health systems, which heavily rely on the many contributions of women to care as members of the health workforce, in which their numbers are rapidly increasing, and in their traditional roles as primary caregivers at home and in communities. Women and Health—the focus of this Commission—is a novel concept that refers to the multifaceted pathways through which women and health interact, moving beyond the traditional and exclusive focus on women’s health to address the roles of women as both users and providers of health care, and highlighting the potential for synergy between them. We envision a virtuous cycle that builds on the premise that women who are healthy throughout their lives experience gender equality and are enabled, empowered, and valued in their societies, including in their roles as caregivers, are well prepared to achieve their potential and make substantial contributions to their own health and wellbeing, to that of their families and communities, and, ultimately, to sustainable development. Such thinking needs an interdisciplinary, cross-sectoral perspective to identify women-centred solutions to the unique obstacles that girls and women face as both consumers and providers of health care. In this Commission, we analyse existing and original evidence about the complex relations between women and health. We examine the major economic, environ mental, social, political, demographic, and epide miological transitions happening worldwide, their implications on the health system, and their eff ects on women and health. The health status of girls and women is analysed using a life-course approach to show the breadth of women’s health beyond the reproductive role. We estimate the fi nancial value of the paid and unpaid health-care-related duties that women undertake in health systems and in their homes and communities, which are a hidden subsidy to health systems and societies. We conclude that gender-transformative policies are needed to enable women to integrate their social, biological, and occupational roles and function to their full capacity, and that healthy, valued, enabled, and empowered women will make substantial contributions to sustainable development (key messages). In view of these issues, we propose crucial actions for development partners, governments, civil society, advocates, academics, and professional associations that are needed to advance the women and health agenda (panel 1).

From evidence to action to deliver a healthy start for the next generation

Remarkable progress has been made towards halving of maternal deaths and deaths of children aged 1-59 months, although the task is incomplete. Newborn deaths and stillbirths were largely invisible in the Millennium Development Goals, and have continued to fall between maternal and child health efforts, with much slower reduction. This Series and the Every Newborn Action Plan outline mortality goals for newborn babies (ten or fewer per 1000 livebirths) and stillbirths (ten or fewer per 1000 total births) by 2035, aligning with A Promise Renewed target for children and the vision of Every Woman Every Child. To focus political attention and improve performance, goals for newborn babies and stillbirths must be recognised in the post-2015 framework, with corresponding accountability mechanisms. The four previous papers in this Every Newborn Series show the potential for a triple return on investment around the time of birth: averting maternal and newborn deaths and preventing stillbirths. Beyond survival, being counted and optimum nutrition and development is a human right for all children, including those with disabilities. Improved human capital brings economic productivity. Efforts to reach every woman and every newborn baby, close gaps in coverage, and improve equity and quality for antenatal, intrapartum, and postnatal care, especially in the poorest countries and for underserved populations, need urgent attention. We have prioritised what needs to be done differently on the basis of learning from the past decade about what has worked, and what has not. Needed now are four most important shifts: (1) intensification of political attention and leadership; (2) promotion of parent voice, supporting women, families, and communities to speak up for their newborn babies and to challenge social norms that accept these deaths as inevitable; (3) investment for effect on mortality outcome as well as harmonisation of funding; (4) implementation at scale, with particular attention to increasing of health worker numbers and skills with attention to high-quality childbirth care for newborn babies as well as mothers and children; and (5) evaluation, tracking coverage of priority interventions and packages of care with clear accountability to accelerate progress and reach the poorest groups. The Every Newborn Action Plan provides an evidence-based roadmap towards care for every woman, and a healthy start for every newborn baby, with a right to be counted, survive, and thrive wherever they are born.

Women and Health: the key for sustainable development. The Lancet Commissions.

Executive summary Girls’ and women’s health is in transition and, although some aspects of it have improved substantially in the past few decades, there are still important unmet needs. Population ageing and transformations in the social determinants of health have increased the coexistence of disease burdens related to reproductive health, nutrition, and infections, and the emerging epidemic of chronic and non-communicable diseases (NCDs). Simultaneously, worldwide priorities in women’s health have themselves been changing from a narrow focus on maternal and child health to the broader framework of sexual and reproductive health and to the encompassing concept of women’s health, which is founded on a life-course approach. This expanded vision incorporates health challenges that aff ect women beyond their reproductive years and those that they share with men, but with manifestations and results that aff ect women disproportionally owing to biological, gender, and other social determinants. The complexity of the challenges faced by women throughout the life course needs an increased focus on health systems, which heavily rely on the many contributions of women to care as members of the health workforce, in which their numbers are rapidly increasing, and in their traditional roles as primary caregivers at home and in communities. Women and Health—the focus of this Commission—is a novel concept that refers to the multifaceted pathways through which women and health interact, moving beyond the traditional and exclusive focus on women’s health to address the roles of women as both users and providers of health care, and highlighting the potential for synergy between them. We envision a virtuous cycle that builds on the premise that women who are healthy throughout their lives experience gender equality and are enabled, empowered, and valued in their societies, including in their roles as caregivers, are well prepared to achieve their potential and make substantial contributions to their own health and wellbeing, to that of their families and communities, and, ultimately, to sustainable development. Such thinking needs an interdisciplinary, cross-sectoral perspective to identify women-centred solutions to the unique obstacles that girls and women face as both consumers and providers of health care. In this Commission, we analyse existing and original evidence about the complex relations between women and health. We examine the major economic, environ mental, social, political, demographic, and epide miological transitions happening worldwide, their implications on the health system, and their eff ects on women and health. The health status of girls and women is analysed using a life-course approach to show the breadth of women’s health beyond the reproductive role. We estimate the fi nancial value of the paid and unpaid health-care-related duties that women undertake in health systems and in their homes and communities, which are a hidden subsidy to health systems and societies. We conclude that gender-transformative policies are needed to enable women to integrate their social, biological, and occupational roles and function to their full capacity, and that healthy, valued, enabled, and empowered women will make substantial contributions to sustainable development (key messages). In view of these issues, we propose crucial actions for development partners, governments, civil society, advocates, academics, and professional associations that are needed to advance the women and health agenda (panel 1).

Consensus on kangaroo mother care acceleration

On Oct 21–22, 2013, stakeholders in newborn health convened in Istanbul, Turkey, to discuss how to accelerate the implementation of kangaroo mother care (KMC) globally. Focused attention on newborn deaths, which now account for 44% of under-5 mortality, is required to accelerate progress toward Millennium Development Goal 4 (to reduce child mortality by twothirds) and beyond. KMC has been proven to reduce newborn mortality, but only a very small proportion of newborns who could benefit from KMC receive it. The Istanbul convening was assembled to accelerate the uptake of this life-saving intervention. We affirm accelerating adoption of KMC, recognising that:

A strategy for reducing maternal and newborn deaths by 2015 and beyond

BackgroundAchievement of Millennium Development Goal (MDG) 4 for child survival requires acceleration of gains in newborn survival, and current trends in improving maternal health will also fall short of reaching MDG 5 without more strategic actions. We present a Maternal Newborn and Child Health (MNCH) strategy for accelerating progress on MDGs 4 and 5, sustaining the gains beyond 2015, and further bringing down maternal and child mortality by two thirds by 2030.DiscussionThe strategy takes into account current trends in coverage and cause-specific mortality, builds on lessons learned about what works in large-scale implementation programs, and charts a course to reach those who do not yet access services. A central hypothesis of this strategy is that enhancing interactions between frontline workers and mothers and families is critical for increasing the effective coverage of life-saving interventions. We describe a framework for measuring and evaluating progress which enables continuous course correction and improvement in program performance and impact.SummaryEvidence for the hypothesis and impact of this strategy is being gathered and will be synthesized and disseminated in order to advance global learning and to maximise the potential to improve maternal and neonatal survival.

Maternal, newborn, and child health and the Sustainable Development Goals--a call for sustained and improved measurement.

Immunisation is one of the great global health successes of th e past century, with millions of lives saved. Ensuring vaccination of millions of children is complex, but is made possible by one fundamental task: systematic counting at multiple levels and at frequent intervals. From charts in thousands of rural health posts, to databases in ministries of health, to standardised surveys and global reports from WHO, UNICEF, and GAVI, the Vaccine Alliance, a robust interconnected system of data collection and use enables health workers, programme managers, and global actors to track who is vaccinated and make course corrections as needed to improve performance, policies, and programmes. Similar large-scale and long-term gains have been made against malaria by way of highly aligned and coordinated global measurement strategies linked to programmes. These characteristics were also a prominent feature of the successful global diarrhoeal disease control programme of the 1980s and early 1990s. “The Three Ones” (ie, one action framework, one national coordinating authority, and one countrylevel monitoring and evaluation system) for HIV promoted harmonised measurement plans that were made possible by an aggressive global capacity-building eff ort. In maternal, newborn, and child health, the counting is more diffi cult than in some other parts of global health, but has never been more crucial. The Sustainable Development Goals (SDGs) call for major reductions in maternal, neonatal, and child mortality and universal access to sexual and reproductive health services by 2030. These aims require further expansion in coverage, quality, and measurement of eff ective interventions. Although the Millennium Development Goals (MDGs) sparked an increase in data collection, most countries still do not have timely data about how many of the women, adolescents, children, and newborns who need eff ective interventions are receiving them. This is unacceptable, and the global health community can do better. Great progress has been made through household survey programmes such as Demographic and Health Surveys and the Multiple Indicator Cluster Surveys, the Countdown to 2015 for Maternal, Newborn and Child Survival (Countdown) eff ort, and the investment and visibility promoted by the Commission on Information and Accountability for Women’s and Children’s Health and its independent Expert Review Group. Yet challenges remain, such as the need for improved standardised data collection and use at the facility level and innovation to address fundamental technical issues. A more robust data system to measure the coverage of interventions known to be eff ective in reducing maternal, newborn, and child mortality—similar to those that currently exist for vaccines and malaria—will be essential to enhance services, improve health, and achieve long-term goals in mortality reduction. Building on, extending, and refi ning this system for measuring maternal, newborn, and child health is an urgent task for the global community, as well as national and local governments. For the DHS Program: Demographic and Health Surveys see http://dhsprogram. com

Improved measurement for mothers, newborns and children in the era of the Sustainable Development Goals

Background An urgent priority in maternal, newborn and child health is to accelerate the scale–up of cost–effective essential interventions, especially during labor, the immediate postnatal period and for the treatment of serious infectious diseases and acute malnutrition. u2009Tracking intervention coverage is a key activity to support scale–up and in this paper we examine priorities in coverage measurement, distinguishing between essential interventions that can be measured now and those that require methodological development. Methods We conceptualized a typology of indicators related to intervention coverage that distinguishes access to care from receipt of an intervention by the population in need. u2009We then built on documented evidence on coverage measurement to determine the status of indicators for essential interventions and to identify areas for development. Results Contact indicators from pregnancy to childhood were identified as current indicators for immediate use, but indicators reflecting the quality of care provided during these contacts need development. At each contact point, some essential interventions can be measured now, but the need for development of indicators predominates around interventions at the time of birth and interventions to treat infections. Addressing this need requires improvements in routine facility based data capture, methods for linking provider and community–based data, and improved guidance for effective coverage measurement that reflects the provision of high–quality care. Conclusion Coverage indicators for some essential interventions can be measured accurately through household surveys and be used to track progress in maternal, newborn and child health. u2009Other essential interventions currently rely on contact indicators as proxies for coverage but urgent attention is needed to identify new measurement approaches that directly and reliably measure their effective coverage.

Uganda Newborn Study (UNEST): learning from a decade of research in Uganda to accelerate change for newborns especially in Africa

No abstract available. (Published: 31 March 2015) Citation : Glob Health Action 2015,xa0 8 : 27363 -xa0 http://dx.doi.org/10.3402/gha.v8.27363 SPECIAL ISSUE : This paper is part of the Special Issue:xa0 Newborn health in Uganda . More papers from this issue can be found atxa0 http://www.globalhealthaction.net

Opening the Black Box for Etiology of Neonatal Infections in High Burden Settings: The Contribution of ANISA

E year an estimated 6.9 million neonates require treatment for possible serious bacterial infection (PSBI) in South Asia and Sub Saharan Africa. PSBI leads to more than 600,000 deaths the majority of which do not receive appropriate antibiotic treatment. There is an additional burden of long-term disability mostly unmeasured. Neonatal infections are the second leading infectious cause of death in children under 5 years old (second to pneumonia), with more annual child deaths than HIV and malaria combined. The global burden of neonatal infection can be reduced by prevention strategies and increased coverage of timely and appropriate therapy for newborns with PSBI. Targeted research is needed to address a pipeline from upstream discovery science research to delivery/implementation research on how best to provide known interventions for all in need (Table 1). Research to open the black box of etiology is crucial throughout this process but must be tied to enhanced implementation. Contextual and environmental changes in the places where births occur, evolution of organisms, notably with resistance and host factors will affect strategies to maximize programmatic impact at scale. As more births occur in hospitals, a crucial priority is to improve quality and measurement of facilitybased care at birth and care of sick newborns. When hospital referral is not possible, treatment with simplified antibiotic regimens initiated at primary clinics is now incorporated into WHO guidelines, and scale-up is underway. Rapid results are possible as learning from implementation research is fed into programs. Upstream research including maternal immunization and novel drugs or drug delivery techniques has potential for impact in the medium to long term. Both research advances and programmatic scale up require knowledge of the changing pattern of cause of death, through improved descriptive epidemiology and etiological data to guide the research and action on neonatal infections (Table 1). Almost all studies on the etiology of neonatal infections are from high-income countries, focus on a single organism (eg, Group B Streptococcus) and are not population based, with the majority of published neonatal infection studies to date focused on neonatal intensive care units. Therefore, the Aetiology of Neonatal Infections in South Asia (ANISA) study is a major accomplishment. The largest ever population-based cohort of ~68,000 newborns, the study includes both sick infants with PSBI and healthy controls. Using a common protocol, the 5 study sites developed strategies for early identification of births and newborn evaluation within 24 hours, standardized techniques for sample collection and processing (cultures and molecular array testing), and systems for data collection and biobanking of samples. The combination of diverse populations and techniques should improve our understanding of etiology beyond a linear single-sample, single-organism model through a richer dataset with relevant contextual and environmental information. The accompanying article in this supplement describe the approach and methods applied to this enormous logistical undertaking, led by Professor Samir Saha, to conduct a study across 3 countries (Bangladesh, India and Pakistan) with over 1000 laboratory, clinical, surveillance and data management staff. Inherent challenges in such large-scale, multisite etiologic studies are addressed, notably:

Global Financing Facility: where will the funds come from?

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