Editorial
Sustainable equality—a goal to aspire to
Article Info
2015 marks a transition point for development which is, in its own way, exhilarating. The Millennium Development Goals (MDGs) will shortly expire, and these familiar and extensively discussed benchmarks can then be judged to have culminated in successes, failures, or opportunities against the extraordinary backdrop of the era—from the response to a catastrophic epidemic of HIV/AIDS to the profound and challenging global shifts in disease epidemiology, demography, and migration. A new set of aspirations must be fashioned to prepare the world's people for times of continuing, indeed perhaps intensifying, change and uncertainty.
Two reports released in June set out to assess the achievements of the MDG process for women's and children's health. State of inequality: Reproductive, maternal, newborn and child health, from WHO, analyses health in a large group of low-income and middle-income countries. Data from 86 countries were studied, with changes over time assessed in 42. The report highlights substantial persisting inequalities, most pronounced in the proportion of births supervised by skilled health workers, with richest and poorest groups differing by up to 80%, and by 37% or more in half of the countries studied. Most countries reported a higher under-5 mortality rate in rural than in urban regions; and in half of the countries studied there was a substantial gap between the richest and poorest groups in seeking care for children with symptoms of pneumonia.
More positively, the WHO report found little or no inequality in immunisation coverage according to sex. There was also evidence of progress in a more rapid decline in the under-5 mortality rate in the poorest than the richest subgroups, in the countries where changes over time could be assessed. With a view to the future, the report focuses on a composite index of eight indicators—ranging from skilled birth attendance to immunisation against measles and DTP3 at the age of 1 year. Recalling that not all developing countries have been included in the study, the report emphasises the importance of robust data collection so that inequalities in coverage by different interventions can be assessed.
A second report released by UNICEF, Progress for children beyond averages: learning from the MDGs, takes a stepwise approach to the MDGs, highlighting areas of progress and ongoing challenges. Although the number of people living in poverty is estimated to have fallen from 1·9 billion in 1990 to 1 billion in 2015, for instance, 47% of those living in extreme poverty today are aged 18 years or younger. There has been a 58% reduction in new HIV infections in children aged 14 years or younger since 2001, but almost two-thirds of new HIV infections today are in girls and women aged 15–19 years. By contrasting successes and failures in several domains, the UNICEF report makes the point that the focus must shift away from national averages to enable greater progress in diminishing inequalities in maternal and child health.
The WHO and UNICEF reports illustrate that dramatic progress is possible where evidence-based interventions can be deployed systematically—often by a synergy between donor resources and expertise, and indigenous people and infrastructure. Determination of what has and has not been achieved is key for programmes to be tailored to new and existing challenges, whether posed by changes in disease incidence or population growth, or by local political obstacles or conflict. However, forms of ill health that are less easy to identify and address, such as mental illness, cannot be excluded from development provision and assessment.
What are the prospects for women's and children's health once the MDGs have been retired? As discussed in the recent Lancet Commission on Women and Health, women's contributions to health care, and vice versa, will be key to achievement of sustainable development. The Sustainable Development Goals (SDGs) are being composed in a process that is, deliberately, more inclusive and comprehensive than that which produced their predecessors. Although health is, at the time of writing, restricted to a single SDG, two explicit goals focus, respectively, on achievement of gender equality and empowerment of all women and girls, and on reduction of inequality within and among countries. The SDGs will result in a complex framework in which health, sustainability, and economics compete for priority. How the new set of goals will be operationalised and evaluated will be fundamental to ensuring that the development trajectory of the 21st century is soundly based—on provision for and equality of all women and children.
