This article was originally posted on the PMNCH website and was written by  Jennifer Requejo, Jonathan D. Klein, and Sophie Arseneault, PMNCH Accountability Working Group Chair and Vice Chairs.

On September 21^st, stakeholders will come together at the United Nations General Assembly to discuss the importance of aligning investments on primary health care as a key pathway for achieving universal health coverage (UHC) (1). This event fulfills the agreement to convene a high-level meeting in 2023 included as part of the Political Declaration of the High-Level Plenary Meeting on Universal Health Coverage resolution adopted by the General Assembly in 2019 (A/RES/74/2) (2).

Latest reports from UHC 2030 show that the positive trajectory from 2019 to 2021 in country commitments to universal health stagnated starting in 2022, and there was systematic underinvestment in reducing financial barriers to health services across many countries (3). UHC 2030 also found continued country reliance on disease-specific programming and wide variations in progress across countries in increasing the service coverage index (Sustainable Development Target 3.8, indicator 3.8.1) *(3).  A critical question is how much these findings reflect the situation for women, children, and adolescents, the population groups at the center of the UHC agenda.

According to the latest United Nations global maternal mortality estimates, progress in reducing maternal mortality stagnated from 2016 to 2020, and the world is off track for achieving Sustainable Development Goal target 3.1 ** (4)(5). Those same estimates, which reflect pre-pandemic levels, translate into approximately 800 maternal deaths every day. These global figures mask large inequalities in maternal mortality across regions and countries, with a growing concentration of maternal deaths in sub-Saharan Africa’s poorest countries and in conflict-affected contexts (4). The most recent stillbirth, neonatal and child mortality estimates show similar patterns. In 2021, there were an estimated 1.9 million stillborn babies, approximately one every 16 seconds (6). Progress in reducing stillbirth rates has been slow, and the highest stillbirth rates were in sub-Saharan Africa (6). Around 2.3 million children died during the first month of life in 2021 – about 6,400 deaths per day (7). Children at greatest risk of dying during the neonatal period were, again, in sub-Saharan Africa (7).

The message is clear about the growing concentration of mortality in sub-Saharan Africa and fragile contexts, and the urgent need to prioritize these settings for action. But these statistics do not tell the whole story. Country efforts to strengthen health service delivery platforms and reduce health inequalities have yielded important results for women and children that should be acknowledged. For example, a recent analysis examining trends in 101 low- and middle-income countries over the past three decades on coverage of the composite coverage index (CCI) – composed of eight essential interventions along the reproductive, maternal, newborn, child, and adolescent health (RMNCAH) continuum of care – found both positive changes in coverage levels as well as significant reductions in inequalities within and between countries (8). The CCI increased approximately 22 percentage points, from an average of 49% coverage across these countries in 1993 to 71% in 2021. Similarly, absolute inequalities in CCI coverage levels between the richest and poorest women and children living in these countries declined, with the coverage gap narrowing from 33 percentage points to 14 percentage points. The study also found that low-income countries experienced the greatest increases in coverage during the last 30 years. However, West and Central Africa performed the poorest, with the lowest coverage levels of the CCI and highest levels of inequalities (8).

Although these study findings paint an optimistic picture of what is possible, they are consistent with the latest assessment of 16 key RMNCAH interventions in the Global Strategy for Women’s, Children’s, and Adolescents’ Health presented at the World Health Assembly in May***.  This assessment showed that despite laudable progress, the world is far from achieving universal coverage for essential RMNCAH services, and the poorest and most vulnerable women and children remain much less likely to receive these services than their wealthier counterparts (9). Similarly, new projections suggest that only 18 of 70 low- and middle-income countries for which data was available will achieve 80% or higher coverage of the CCI by 2030 (10).

What can we do to re-build momentum as the world recovers from the COVID19 pandemic and accelerate access to high quality essential health services for all women and children?

The September 21^st High Level Meeting on Universal Health Coverage is a pivotal moment for country governments and stakeholders to recommit to the primary health care approach as the bedrock to the achievement of UHC.

The Declaration of Astana resulting from the Global Conference on Primary Health Care in 2018 describes the three pillars of the primary health care approach, which are foundational to ensuring all women, children, and adolescents receive the care they need to survive and thrive (11). These pillars emphasize the importance of resilient health care systems able to provide high quality health services throughout the life course, the need for coordinated multi-sectoral actions and a whole-of-government approach to best address underlying determinants of health, and community engagement – including meaningful adolescent and youth participation – to ensure health care services are responsive to the needs of people and to hold governments to account for delivering on their UHC commitments.

There have been important strides in each of these three pillars in recent years that should be continued. Growing recognition of the interconnectedness of maternal and newborn health, for example, has resulted in strategic alignment between the Every Newborn Action Plan (ENAP) and Ending Preventable Maternal Mortality (EPMM) initiatives, with unified messages on service integration as key to saving maternal and newborn lives, and on the importance of partners and countries working together to build health care systems that provide comprehensive, high quality RMNCAH services from the community level to health posts and all the way up to intensive care facilities (12). The establishment of the Child Survival Action initiative launched in April 2023 (13) and its linkage to ENAP and EPMM is another example of the global community’s efforts to operationalize the life-course paradigm and ensure continuity of care throughout the pre-pregnancy, pregnancy, postpartum, and childhood periods.

The launch of the Catalytic Fund for the Community Health Road Map in 2020 was also a major step forward for bringing together Ministries of Health, partners, and donors to identify priorities and invest in community health systems (14). Women and children are primary beneficiaries of community health care programs that reach them where they live, and their scale up is an important strategy for bringing services to zero dose communities. New country commitments to adolescent health and well-being that will be made in the context of the SDG Summit and at the upcoming Global Forum for Adolescents (15) is an important milestone for increasing visibility and funding to this population group who will become future leaders and parents of the next generation. Regarding human resources for health, the COVID19 pandemic further reinforced awareness of health care workers as the backbone of health care systems, and the need for governments and partners to adequately invest in their training and in creating enabling environments for them so they can provide respectful care according to standards. Ensuring sufficient numbers of well-trained health care workers who are equitably distributed throughout countries is fundamental to achieving universal coverage of the services all women and children deserve.

Together, by re-committing to the UHC agenda, reaffirming the principles of the primary health care approach, investing in innovations (16), and strengthening social participation mechanisms, we can make greater strides towards the health-related SDGs and achieve the ultimate goal of good health and well-being for women and children everywhere.

^ Partnership for Maternal, Newborn & Child Health (PMNCH) Accountability Working Group Members (in alphabetical order):  Sana Contractor, Theresa Diaz, Lucy Fagan, Vineeta Gupta, Susannah Hurd, Dan Irvine, Mande Limbu, Jaideep Malhotra, Esther Nasikye, Harriet Nayiga, Oyeyemi Pitan, Petrus Steyn, Guknur Topcu. Leadership and Management of the group:  Jennifer Requejo (co-chair), Jonathan D. Klein (vice chair), Sophie Arseneault (vice chair, under 30 years of age), Ilze Kalnina (PMNCH Secretariat).

*SDG 3.8. Achieve universal health coverage, including financial risk protection, access to quality essential health-care services and access to safe, effective, quality, and affordable essential medicines and vaccines for all.  The indicator 3.8.1 refers specifically to coverage of essential health services defined as the average coverage of essential services based on tracer interventions that include reproductive, maternal, newborn and child health, infectious diseases, non-communicable diseases and service capacity and access, among the general and most disadvantaged population.  More information on the metadata including for the service coverage index is available here:  https://unstats.un.org/sdgs/metadata/files/Metadata-03-08-01.pdf

**SDG 3.1. By 2030, reduce the global maternal mortality ratio to less than 70 per 100,000 live births.  3.1.1 is the maternal mortality ratio indicator.

*** The list of 16 indicators assessed include: treatment of pregnant women living with HIV; postnatal visit for babies; immunization with rotavirus vaccine; skilled attendant at delivery; antenatal care (at least four visits); postnatal visit for mothers; population using at least basic drinking water services; care-seeking for children under 5 years of age with symptoms of pneumonia; early initiation of breastfeeding; exclusive breastfeeding; demand for family planning satisfied with modern contraceptive methods; oral rehydration solution treatment for diarrhoea for children under 5 years of age; continued breastfeeding (for the first year); measles vaccination; DTP3 vaccination.

References

1. UHC Action Agenda.  https://www.uhc2030.org/un-hlm-2023/action-agenda-from-the-uhc-movement/#:~:text=What%20is%20the%20UHC%20Action,health%20for%20all%20by%202030.  Accessed September 11, 2023.
2. Political declaration of the high-level meeting on universal health coverage. 2019. A/RES/74/2  https://documents-dds-ny.un.org/doc/UNDOC/GEN/N19/311/84/PDF/N1931184.pdf?OpenElement.  Accessed September 11, 2023.
3. State of UHC Commitment Review: Key findings. https://www.uhc2030.org/fileadmin/uploads/uhc2030/SoUHCc_key_findings_summary_EN.pdf. Accessed September 11, 2023.
4. Trends in maternal mortality 2000 to 20202: estimates by WHO, UNICEF, UNFPA, World Bank Group and UNDESA/Population Division.  Geneva:  World Health Organization, 2023.  Licence: CC BY-NC-SA 3.0 IGO. https://www.who.int/publications/i/item/9789240068759
5. Transforming our world: The 2030 Agenda for Sustainable Development. https://sdgs.un.org/2030agenda.  Accessed September 11, 2023.
6. United Nations Inter-Agency Group for Child Mortality Estimation (UNIGME), Never Forgotten:  The situation of stillbirth around the globe, United Nations Children’s Fund, New York, 2023.
7. United Nations Inter-agency Group for Child Mortality Estimation (UNIGME), Levels & Trends in Child Mortality:  Report 2022, Estimates developed the United Nations Inter-agency Group for Child Mortality Estimation, United Nations Children’s Fund, New York, 2023.
8. Barros AJ, Blumenberg C.  OP89 Are we making progress in reproductive, maternal, neonatal, and child health (RMNCH) ?  Change in coverage and equity of essential interventions in 101 countries using the composite coverage index.  J Epidemiol Community Health 2023 ;77 : A44.
9. Global Strategy for Women’s, Children’s, and Adolescents’ Health (2016-2030).  Report by the Director General.  Executive summary.  76th World Health Assembly, Provisional Agenda Item 12, April 6, 2023. A76/5. https://apps.who.int/gb/ebwha/pdf_files/WHA76/A76_5-en.pdf.
10. Rahman M, Rouyard T, Khan ST, Nakamura R, Isla R, Hossain S et al., Reproductive, maternal, newborn, and child health intervention coverage in 70 low-income and middle-income countries, 2000-30 : trends, projections, and inequities.  Lancet Global Health, published online September 4, 2023, https://doi.org/10.1016/S2214-109X(23)00358-3.
11. Declaration of Astana.  Global Conference on Primary Health Care, Astana, Kazakhstan, 25-26 October 2018. https://www.who.int/publications/i/item/WHO-HIS-SDS-2018.61.  Accessed September 11, 2023.
12. World Health Organization, UNFPA, UNICEF.  Improving maternal and newborn health and survival and reducing stillbirth – Progress report 2023.  https://www.who.int/publications/i/item/9789240073678.  Accessed September 11, 2023.
13. Child Survival Initiative.  https://www.childhealthtaskforce.org/hubs/child-survival-action. Accessed September 11, 2023.
14. Community health road map.  https://www.communityhealthroadmap.org/.  Accessed September 11, 2023.
15. Global Forum for Adolescents. https://www.1point8b.org/.  Accessed September 11, 2023.
16. Bill & Melinda Gates Foundation and the Institute for Health Metrics. Goal Keepers Report.  2023. Imagine a World :  Where innovations could save the lives of 2 million more mothers and babies. https://www.gatesfoundation.org/goalkeepers/report/2023-report/.  Accessed September 13, 2023.

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