Elsevier

The Lancet

Volume 391, Issue 10129, 14–20 April 2018, Pages 1538-1548
The Lancet

Review
Countdown to 2030: tracking progress towards universal coverage for reproductive, maternal, newborn, and child health

https://doi.org/10.1016/S0140-6736(18)30104-1Get rights and content

Summary

Building upon the successes of Countdown to 2015, Countdown to 2030 aims to support the monitoring and measurement of women's, children's, and adolescents' health in the 81 countries that account for 95% of maternal and 90% of all child deaths worldwide. To achieve the Sustainable Development Goals by 2030, the rate of decline in prevalence of maternal and child mortality, stillbirths, and stunting among children younger than 5 years of age needs to accelerate considerably compared with progress since 2000. Such accelerations are only possible with a rapid scale-up of effective interventions to all population groups within countries (particularly in countries with the highest mortality and in those affected by conflict), supported by improvements in underlying socioeconomic conditions, including women's empowerment. Three main conclusions emerge from our analysis of intervention coverage, equity, and drivers of reproductive, maternal, newborn, and child health (RMNCH) in the 81 Countdown countries. First, even though strong progress was made in the coverage of many essential RMNCH interventions during the past decade, many countries are still a long way from universal coverage for most essential interventions. Furthermore, a growing body of evidence suggests that available services in many countries are of poor quality, limiting the potential effect on RMNCH outcomes. Second, within-country inequalities in intervention coverage are reducing in most countries (and are now almost non-existent in a few countries), but the pace is too slow. Third, health-sector (eg, weak country health systems) and non-health-sector drivers (eg, conflict settings) are major impediments to delivering high-quality services to all populations. Although more data for RMNCH interventions are available now, major data gaps still preclude the use of evidence to drive decision making and accountability. Countdown to 2030 is investing in improvements in measurement in several areas, such as quality of care and effective coverage, nutrition programmes, adolescent health, early childhood development, and evidence for conflict settings, and is prioritising its regional networks to enhance local analytic capacity and evidence for RMNCH.

Introduction

The Millennium Development Goals (MDGs) era was characterised by an unprecedented decline in child and maternal mortality during 2000–15, even though mortality targets were not met by most countries.1, 2, 3, 4 Concerted action around the MDGs—specific time-bound, measurable, and easy-to-communicate goals—plus major increases in funding for health, including for reproductive, maternal, newborn, and child health (RMNCH) and nutrition, and scale-up of existing and new interventions are crucial factors that contributed to this decline.5, 6, 7 Progress was also driven by reductions in fertility and substantial improvements in underlying determinants, such as poverty and education of adolescent girls.8, 9, 10, 11 Health was prominently featured in three MDGs, two of which were specific to RMNCH. The 2030 agenda for sustainable development, adopted by the UN General Assembly in September, 2015, is much broader than the MDG framework.12 RMNCH is addressed in three of the 13 targets of the Sustainable Development Goal (SDG) for health (SDG 3), and in several targets in the other 16 SDGs. The need to reduce persistent inequalities in RMNCH between and within countries is explicitly acknowledged, as is the aim of reaching all people with effective and affordable interventions.

The Global Strategy for Women's, Children's and Adolescents' Health (2016–30) was developed to translate the SDG agenda into a comprehensive “survive, thrive, transform” framework for improving women's, children's, and adolescents' health through an inclusive and multisectoral approach.13, 14 The Global Strategy provides a roadmap for the Every Woman Every Child movement, which mobilises and intensifies international and national action by governments, multilaterals, the private sector, and civil society to address the major health challenges facing women, children, and adolescents around the world. The Global Financing Facility for women, children, and adolescents was also launched in 2015 to ensure scaled and sustained financing through country-driven investment cases.15

Key messages

  • The 81 Countdown countries have made progress, but are still a long way from universal coverage for most essential interventions for reproductive, maternal, newborn, and child health and nutrition.

  • Major investments are needed to achieve Sustainable Development Goal (SDG) targets related to reproductive, maternal, newborn, and child health and nutrition. These investments should be guided by reliable data on intervention coverage and quality of care for all inequality dimensions and in conflict settings.

  • To address the broader SDG agenda, measurement improvements should focus on strengthening of vital statistics, understanding drivers of coverage change, and obtaining better data on early childhood development and adolescent health.

  • Strengthening of countries' analytic capacity, a priority for the Countdown to 2030, is crucial to improve monitoring and accountability for women's, children's, and adolescents' health.

Countdown to 2030 for Women's, Children's and Adolescents' Health (referred to simply as Countdown) is a multi-institutional network of academics from institutions around the world and representatives from UN agencies and civil society that builds upon the successes of Countdown to 2015.6, 16 A key output of Countdown is a regular review of progress towards RMNCH targets in the 81 countries with the highest burden of maternal, neonatal, and child mortality. According to global estimates for population and mortality, the 81 countries accounted for 47% of the world's population, but 64% of all births, 90% of all child deaths, and 95% of all maternal deaths in 2015.1, 2, 17 The Countdown list of priority countries, core indicators, and equity dimensions were revised to address the SDG agenda, and to take into account country progress during the MDG era (appendix). Areas of expansion from Countdown to 2015 include nutrition, quality of care, adolescent girls' reproductive health, and RMNCH in conflict settings.

In this paper, we analyse progress towards improvement of intervention coverage, equity, and drivers of RMNCH in the Countdown countries, summarise key gains, highlight areas for further action, and show how Countdown priorities are evolving in response to the SDGs and universal health coverage (UHC) challenge.

Section snippets

Maternal, neonatal, and child survival

From 2000 to 2015, under-5 and neonatal mortality in the 81 Countdown countries fell rapidly, to country averages of 59 and 24 per 1000 livebirths, respectively, in 2015.18 However, a major acceleration of this mortality decline is required for countries to reach the SDG under-5 and neonatal mortality targets of 25 and 12 per 1000 livebirths, respectively, especially among the countries with the highest mortality. The average annual rates of decline in the 50 Countdown countries with the

Nutritional status

Undernutrition—including fetal growth restriction, stunting and wasting, and deficiencies in micronutrients such as vitamin A, iodine, iron, and zinc—along with suboptimal breastfeeding has been estimated to contribute to 45% of deaths in children younger than 5 years in 2011, and to poor childhood development.25, 26 Levels of stunting in under-5s have dropped substantially in the past decade,27 but 31 of the 59 Countdown countries with available data from 2012 still have a national prevalence

Coverage

Household surveys are the main source of data used to compare coverage trends and inequalities between and within countries. We have previously reported on Countdown's data sources and methods (appendix).6 Data availability for Countdown coverage indicators has improved considerably since 2005, partly because of the increased frequency of surveys done in the context of international household survey programmes—such as the USAID-supported Demographic and Health Surveys and UNICEF-supported

Equity

Progress towards universal coverage should be assessed in terms of not only national averages, but also how well such gains benefit all population groups. Survey data were used to classify households into wealth quintiles on the basis of ownership of household assets and housing characteristics.33 We use the slope index of inequality, which measures the difference in coverage between the richest and poorest extremes of the wealth scale and takes into account the full wealth distribution, to

Drivers

The SDGs stress the need to address the drivers or determinants of women's, children's, and adolescents' health, including health system, socioeconomic, cultural, political, and environmental factors. For some key drivers, such as women's empowerment, a positive association with coverage of RMNCH interventions has been shown.35 The effect of conflict, both during and after, on women's and children's health can be devastating (panel).

Countdown reports on a set of 17 indicators related to four

Progress towards universal coverage: still much to do

Three main conclusions emerge from our analysis of coverage, equity, and drivers of RMNCH in the 81 Countdown countries. First, strong progress in the coverage of many essential RMNCH interventions was made during the past decade, but many countries are still a long way from universal coverage for most essential interventions. Furthermore, there is growing evidence of the low quality of services because of a lack of basic inputs, such as medicines and trained health workers, which limits the

Measurement and monitoring gaps

An important limitation of our analysis of progress was the poor availability of empirical data in the past 5 years (and especially since 2015) for key indicators and inequality dimensions. Despite major improvements in data collection, there are not enough datapoints to assess whether the rate of improvement in survival or programme performance noted during the MDG era is accelerating or not. Countdown makes only limited use of predictions and aims as much as possible, to allow country data to

Transformation of the Countdown

The SDGs call for a comprehensive and integrated health agenda, with UHC at the centre of the health goal. The Every Woman Every Child Global Strategy for Women's, Children's and Adolescents' Health translates the SDG framework into a comprehensive “survive—thrive—transform” framework that goes well beyond RMNCH.13 Countdown is responding to this new agenda in several ways, while preserving its core features. Countdown will continue to publish independent comprehensive analyses of progress

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