Global Strategy for Women’s, Children’s and Adolescents’ Health (2016–2030): early childhood development: report by the Director-General

EXECUTIVE BOARD EB142/19 142nd session 4 December 2017 Provisional agenda item 4.3 Global Strategy for Women’s, Children’s and Adolescents’ Health (2016–2030): early childhood development Report by the Director-General 1. Pursuant to resolution WHA69.2 (2016), the present report presents new data and initiatives concerning women’s, children’s and adolescents’ health. As indicated by the Secretariat in its report on this subject to the Seventieth World Health Assembly, 1 this report also gives special consideration to early childhood development. In 2018, a report on the Global Strategy for Women’s, Children’s and Adolescents’ Health will be made available on the Global Health Observatory data portal,2 including the full set of 60 indicators, with an analysis of progress to date and details of strategic priorities that will be highlighted in the report to be submitted to the Health Assembly in May 2018. STATUS OF WOMEN’S, CHILDREN’S AND ADOLESCENTS’ HEALTH 2. Universal health coverage is technically and financially possible. While there exists a range of evidence-based, cost-effective interventions and health systems strategies to support countries as they move towards universal health coverage, the returns are highest when investments are made across the life course, targeting those most often left behind – women, children, adolescents and older people in the poorest communities. These population groups are even more vulnerable in the humanitarian crises and fragile settings that need to be addressed in order to achieve the Sustainable Development Goals. For example, an estimated 26 million women and girls of reproductive age live in emergency situations, and all of them need sexual and reproductive health services. 3 An estimated 246 million children (75 million of whom were under 5 years) lived in conflict zones in 2015. 4 As a result of disruption and lawlessness, violence, abuse and neglect, children are exposed to traumatic experiences that pose a major risk to their health and development. Moreover, sexual violence often occurs more frequently during emergencies, exacerbating threats to the health and survival of women and girls, men and boys. 1 Document A70/37. 2 See Global Health Observatory data repository (http://apps.who.int/gho/data/node.gswcah, accessed 13 November 2017). 3 Askew I. et al. Sexual and reproductive health rights in emergencies. Bull World Health Organ. 2016;94:311 (http://www.who.int/bulletin/volumes/94/5/16-173567.pdf, accessed 24 October 2017). 4 Early Moments Matter for every child. New York: United Nations Children’s Fund; September 2017 (https://www.unicef.org/media/files/UNICEF_Early_Moments_Matter_for_Every_Child_report.pdf, accessed 24 October 2017). EB142/19 2 Strengthening data related to women, children and adolescents 3. Work is being done to strengthen existing indicators. For example, indicator 3.1.2 (the proportion of births attended by skilled health personnel) under Sustainable Development Goal 3 (Ensure healthy lives and promote well-being for all at all ages), a critical coverage indicator for maternal and newborn survival, is currently difficult to measure at country level because of the lack of clear guidelines and standardized occupation titles and functions. Countries have found large gaps between current standards and the competences and skills of birth attendants, namely, in respect of their ability to correctly manage uncomplicated childbirth and the immediate postnatal period. In order to assess progress in the proportion of births attended by skilled health personnel, at country and global level, definitions and measurements will have to be improved. WHO, UNFPA, UNICEF, the International Confederation of Midwives, the International Council of Nurses, the International Federation of Gynecology and Obstetrics and the International Pediatric Association have tackled this challenge by engaging in a broad Member State and stakeholder consultation, for developing a joint statement1 on an update on definition of “skilled health personnel”. The update is particularly relevant for the Global Strategy and the Sustainable Development Goals, and will inform the revision of the International Standard Classification of Occupations by ILO. Women’s health 4. WHO support for Family Planning 2020 goals. Under Family Planning 2020, WHO committed to expand contraceptive access, choice and method mix through research and development; to assess the safety and efficacy of new and existing methods; and to scale up the availability of high-quality contraceptive commodities through product prequalification and Expert Review Panel fast-track mechanisms. In 2015 and 2016, therefore, it added the etonogestral-releasing implant, the levonogestral- releasing intrauterine system and the progesterone vaginal ring to the Model List of Essential Medicines. WHO also works to synthesize and make available evidence on effective family planning delivery models and actions, to inform policies, address barriers and strengthen programmes. For example, in order to build a sound understanding of the unmet contraceptive needs of adolescents across countries, it has participated in a literature review 2 and published fact sheets 3 on adolescent contraceptive use in 58 low- and middle-income countries that provide data on contraceptive use among married and unmarried women, the types of contraception they use, where they obtain contraception, and the reasons for not using contraception. Its analyses indicate that contraceptive uptake is usually poor in low- and middle- income countries and that the reasons for non-use are diverse. 5. Safe abortion. According to recent estimates, 56 million induced abortions were performed each year worldwide between 2010 and 2014. From 1990 to 2014, the abortion rate declined markedly in developed regions, from 46 to 27 per 1000 women, but remained the same in developing regions. 4 1 Available at http://www.who.int/reproductivehealth/skilled-birth-attendant/en/ (accessed 25 October 2017). 2 Hindin MJ et al. Interventions to Prevent Unintended and Repeat Pregnancy Among Young People in Low- and Middle-Income Countries: A Systematic Review of the Published and Gray Literature. Journal of Adolescent Health, September 2016;59(3 Supp.):S8-15 (http://www.jahonline.org/article/S1054-139X(16)30061-1/fulltext, accessed 25 October 2017). 3 See http://www.who.int/reproductivehealth/topics/adolescence/contraceptive-use/en/. 4 Sedgh G et al. Abortion incidence between 1990 and 2014: global, regional, and subregional levels and trends. Lancet. May 2006;388(10041):258–267 (http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)30380- 4/fulltext, accessed 25 October 2017). EB142/19 3 6. According to recent research on the safety of abortion, about 25 million of the estimated 56 million abortions performed between 2010 and 2014 were unsafe. Over 75% of abortions in Africa and Latin America were unsafe, and in Africa nearly half of all abortions were performed in the least safe circumstances, by untrained persons using traditional and invasive methods. 1 7. In collaboration with the United Nations Department of Economic and Social Affairs, the Special Programme of Research, Development and Research Training in Human Reproduction has launched the open-access Global Abortion Policies Database, 2 containing abortion laws, policies, health standards and guidelines for all WHO and United Nations Member States. In addition to providing data on specific abortion policies, country profiles include sexual and reproductive health indicators, the list of human rights treaties ratified by the country in question, and links to the concluding observations of United Nations treaty bodies with selected extracts relating to abortion. 8. Cervical cancer. In 2012, more than 528 000 women developed, and over 266 000 women died from, cervical cancer. 3 And yet, cervical cancer can be eliminated, and no woman should die from it. The political will to prevent the disease is stronger than ever, and cost-effective tools exist (human papillomavirus vaccine and DNA testing, screening and treatment). To spur progress and promote the scaling-up of national action, seven United Nations agencies (WHO, IAEA, IARC, UNAIDS, UNFPA, UNICEF and UN Women) established the five-year United Nations’ Joint Global Programme on Cervical Cancer Prevention and Control. The Joint Programme aims to help countries prioritize action for optimal results. It brings together the major players involved in cervical cancer prevention. Six priority countries – one from each of the six WHO regions – have been selected for amplified action. 9. Violence against women. Millions of women globally experience violence, primarily from partners and other family members and with grave consequences to their health. In May 2016, the Sixty-ninth World Health Assembly adopted resolution WHA69.5, in which it endorsed the WHO global plan of action to strengthen the role of the health system within a national multisectoral response to address interpersonal violence, in particular against women and girls, and against children. The Secretariat is working with Member States to facilitate the uptake of clinical and policy guidelines and training tools for responding to violence against women. 4 An increasing number of Member States are developing or updating their national protocols for a health response to violence against women in line with WHO guidelines. This momentum needs to be maintained in order to achieve the objectives of the global plan of action on violence, the “transform” objective of the Global Strategy for 1 Ganatra B et al. Global, regional, and subregional classification of abortions by safety, 2010-14: estimates from a Bayesian hierarchical model. Lancet. September 2017 (Online First publication, http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)31794-4/fulltext, accessed 25 October 2017). 2 See http://www.srhr.org/abortion-policies and https://esa.un.org/gapp (both accessed 25 October 2017). 3 See GLOBOCAN 2012: Estimated Cancer Incidence, Mortality and Prevalence Worldwide in 2012 (http://globocan.iarc.fr/Pages/fact_sheets_cancer.aspx, accessed 13 November 2017). 4 Responding to intimate partner violence and sexual violence against women: WHO clinical and policy guidelines. Geneva: World Health Organization; 2013 (http://apps.who.int/iris/bitstream/10665/85240/1/9789241548595_eng.pdf?ua=1, accessed 13 November 2017); and Health care for women subjected to intimate partner violence or sexual violence.(Document WHO/RHR/14.26; http://apps.who.int/iris/bitstream/10665/136101/1/WHO_RHR_14.26_eng.pdf?ua=1 (accessed 13 November 2017). EB142/19 4 Women’s, Children’s and Adolescents’ Health and targets 5.2 and 5.3 of Sustainable Development Goal 5 (Achieve gender equality and empower all women and girls). 1 Child health 10. The transition from the Millennium to the Sustainable Development Goals provides a timely opportunity to rethink and adapt global strategies on child health and associated programmes. The fact that under-5 mortality has been halved in the past two decades, changes in the age, causes and spatial location of child deaths, and mounting recognition of the importance of taking action to help children who survive grow and thrive are all catalysts for a strategic reconsideration of the global approach to child health. 11. Together with UNICEF, WHO has launched an initiative to redesign child health guidelines, specifically by looking into the changes required to revise the child health policies and programmes that will define universal health coverage during the first 18 years of life. The initiative focuses on both “survive” and “thrive” interventions up to the age of 18 and accepts that the diversity of social, epidemiological and demographic conditions requires context-specific approaches; it is therefore working to define a manageable set of new typologies and suggest a series of evidence-based activities that are likely to improve the health status of children. 12. As a first step in this direction, new global and regional estimates of adolescent (10–19 years) mortality and disability-adjusted life years lost were released in May 2017, and child mortality figures for under-5s and those aged 5–14 years were released on 19 October 2017. Adolescent health 13. In its 2017 report, Transformative accountability for adolescents, 2 the Every Woman Every Child’s Independent Accountability Panel issued an urgent appeal for strategic investments in 10–19 year olds, with a view to achieving the 2030 Agenda for Sustainable Development. 14. Following the release of implementation guidance for Global Accelerated Action for the Health of Adolescents (AA-HA!) 3 in May 2017, several Member States have started developing comprehensive national strategies and plans. By the end of 2017, intercountry meetings to spearhead use of the guidance will have been jointly organized by WHO, the other H6 partners and UNESCO in Caribbean and African countries. Capacity-building activities for use of the guidance will be undertaken in other regions in the first half of 2018. Also, new adolescent health statistics have been released and are available on the Global Health Observatory data portal. 1 Global plan of action to strengthen the role of the health system within a national multisectoral response to address interpersonal violence, in particular against women and girls, and against children. Geneva: World Health Organization; 2016 (http://www.who.int/reproductivehealth/publications/violence/global-plan-of-action/en/, accessed 13 November 2017). 2 Available at http://iapreport.org/files/IAP%20Annual%20Report%202017-online-final-web_with%20endnotes.pdf (accessed 1 November 2017). 3 Available at http://apps.who.int/iris/bitstream/10665/255415/1/9789241512343-eng.pdf?ua=1 (accessed 25 October 2017). EB142/19 5 15. WHO has worked with partners on the Global Early Adolescent Study, which aims to generate knowledge of the ways in which gender norms are formed in early adolescence and how they subsequently predispose young people to sexual and other health risks. Phase I of the Study, conducted in 15 countries, has generated valuable information 1 and contributed to the development of a tool kit to assess gender norms in early adolescence. 2 16. WHO is working with other members of the United Nations Inter-Agency Network on Youth Development to develop a United Nations strategy on youth. The aim is to ensure adolescents and young adults (ages 10–30) are recognized and helped to achieve fulfilling lives and unleash their potential as positive and active agents of change, by 2030. As a first step in this process, in June 2017 an open global survey was made available to each and every young person anywhere in the world. This survey is a way for the United Nations to establish what the priority issues are for young people, what the United Nations can do to tackle these issues and how it can best engage with young people in the process. 17. The Compact for Young People in Humanitarian Action, which was adopted at the World Humanitarian Summit in 2016, will further strengthen the role of young people and empower them as agents of change. It calls for the full inclusion and participation of young people in the prevention, preparedness, and response and recovery processes in relation to humanitarian crises. Financing investment in women, children and adolescents 18. Resources from the Global Financing Facility Trust Fund have currently been allocated to 16 countries. As at July 2017, US$ 525 million had been contributed to the Trust Fund. The first replenishment was launched in September 2017 and aimed to mobilize an additional US$ 2 billion to enable the Facility process to be expanded over the period 2018–2023 to the 50 countries facing the most significant needs (the 16 current beneficiaries plus 34 other countries). WHO has been an active partner of the Facility and has played a key role in helping Member States to prepare their investment cases. Health and human rights 19. Pursuant to the recommendations of the High-Level Working Group on the Health and Human Rights of Women, Children and Adolescents, issued in 2017, WHO and the Office of the High Commissioner for Human Rights are working on a framework cooperation agreement to implement the Working Group’s recommendations, build institutional capacity and expertise, and ensure ongoing monitoring of progress. EARLY CHILDHOOD DEVELOPMENT 20. Early childhood development is essential for the transformation sought under the 2030 Agenda for Sustainable Development. The concept covers childhood from conception to 8 years of age. It encompasses cognitive, physical, language, temperamental, socioemotional and motor development. 1 The global early adolescent study: an exploration of the factors that shape adolescence. J Adolesc Health. October 2017; 61, Issue 4: S1-S54 (http://www.jahonline.org/issue/S1054-139X(17)X0014-1, accessed 13 November 2017). 2 Available at http://www.geastudy.org/quant-download/ (accessed 13 November 2017). EB142/19 6 Development starts at conception. It is during the first 1000 days from conception, during which the brain develops at an astounding pace, that it is most critical for the fetus and the child to receive nurturing care; this is also when children are most responsive to interventions. 21. The most formative experiences of newborns and young children come from nurturing care, which is characterized by a stable environment that promotes health and optimal nutrition, protects children from threats and provides opportunities for early learning through affectionate interactions and relationships. Parents and other primary caregivers are the main providers of nurturing care; policies, information and services must therefore be designed to give them the knowledge, time and material resources needed for appropriate child care. 22. Poverty, any form of malnutrition, low levels of parental education, violence in the home and community, and poor environmental health are among the major risk factors for suboptimal child development. According to conservative estimates based on the risk factors of poverty and stunting alone, 249 million children (43%) in low- and middle-income countries are at risk of not attaining their full development potential, 1 resulting in massive costs for individuals, societies, and current and future generations. Those affected by a poor start in life are estimated to suffer a loss of about a quarter of average adult income per year, while countries may forfeit a sum that can be as much as twice the amount of their current gross domestic product expenditure on health and education. 23. Given the critical importance of enabling children to make the best start in life, the health sector has a responsibility to support nurturing care. Many interventions for reproductive, maternal, newborn, child and adolescent health (including newborn care, nutrition, mental health, HIV prevention and care) have a direct impact on child development. Moreover, the health sector is in a unique position to reach out to families and caregivers during the early years. 24. In support of the Sustainable Development Goals, in particular target 4.2 (ensure that all girls and boys have access to good-quality early childhood development), and the Global Strategy objectives (survive, thrive and transform), WHO is working with UNICEF, the Partnership for Maternal, Newborn and Child Health, and the Action Network for Early Childhood Development to draft a global framework for nurturing care, to facilitate action and results. The framework will focus on the first 1000 days from conception within a life course approach; it will speak to all relevant sectors through the health sector. Consultations were started during a WHO technical meeting in July 2017 and are being held in all regions. An online consultation on the draft framework is being completed. In support of the framework, WHO is also developing guidelines for nurturing care in early childhood and leading a global effort to develop a measurement framework and additional indicators to assess child development in children under the age of 3 years. Care for child development, 2 an approach for strengthening services to support responsive caregiving and early learning, is being scaled-up in at least 25 countries. 1 Lu C et al. Risk of poor development in young children in low-income and middle-income countries: an estimation and analysis at the global, regional, and country level. The Lancet Global Health. December 2016;4(12);e916–e922 (http://www.thelancet.com/journals/langlo/article/PIIS2214-109X(16)30266-2/fulltext, accessed 26 October 2017). 2 WHO/UNICEF. Care for Child Development. Geneva: World Health Organization; 2012. EB142/19 7 FUTURE DEVELOPMENTS 25. Midwifery care is essential to improve maternal and newborn health. Midwife-led continuity-of- care models, in which a midwife or a small group of midwives support women throughout pregnancy, in childbirth and during the postnatal period, identifying and referring them only when needed, lead to better maternal and newborn outcomes. To explore what can and needs to be done in full, it is proposed that the Secretariat’s report on implementation of the Global Strategy to a future session of the Executive Board examine how to extend midwifery care to all women and newborns. ACTION BY THE EXECUTIVE BOARD 26. The Board is invited to note the report. = = =