Maternal, Newborn, Child and Adolescent Health and Well-Being: A Critical Agenda for the G20

Task Force 6: Accelerating SDGs: Exploring New Pathways to the 2030 Agenda

Abstract

The G20 is committed to improved health and well-being and has created Development and Health Working Groups to focus on the task. Within the context of the Decade of Action for Agenda 2030, this Policy Brief reviews the current state of maternal, newborn, child and adolescent health and well-being (MNCAH&W) in G20 countries, examines how outcomes have been affected by the Covid-19 pandemic, and offers specific recommendations for how G20 countries can recover lost gains for this demographic. Recommendations are aligned with the current health priorities of G20 that emphasise prevention, preparedness and response to health emergencies, digital health innovation, and solutions to aid Universal Health Coverage and strengthening the global health architecture. It recommends that G20 countries increase their investments to improve MNCAH&W in order to recover from the Covid-19 pandemic and nurture the sustainable social and economic development of societies for present and future generations.

1. The Challenge

The health and well-being of women, children, and adolescents is central to the development of a country’s human capital and therefore deserves focused attention. Globally, millions of women, children and adolescents are unable to realise their right to health, development and well-being because of poverty, food insecurity, lack of access to quality health services, and the absence of education and social protection policies. In the current era of rapid technological innovations, entire population groups are being left behind, thereby increasing inequities that lead to conflicts and migration, and environmental degradation that sustain the vicious circles of intergenerational poverty. The Covid-19 pandemic and ever-growing threats associated with climate change are further exacerbating the situation.

The imperative of investing in MNCAH&W

There are six key reasons for investing in MNCAH&W:

  1. Human rightsInvesting in the health and well-being of women, children and adolescents is not one policy option among many; it is an end in itself and a human rights imperative and therefore a basic duty of governments.[1] Compared with adults, children and adolescents have less agency to demand their rights, and therefore governments have a duty to help them realise their rights and to provide access to services that promote their health and well-being.
  2. The burden of disease and injury and the demographic and epidemiological transitionChildren and adolescents (<20y) make up one-third of the global population, with women of childbearing age adding another quarter; overall, therefore, women, children and adolescents comprise over half of the world’s people.[2] It would do the global community well to not neglect the health and well-being of these cohorts and the so-called ‘demographic dividend’ they bring to the future wealth and welfare of societies. The adverse consequences of the climate emergency and the changing nature of work, with higher skill requirements, have increased the urgency of ensuring the health and well-being of these population groups and equipping them with 21st-century skills.To be sure, mortality rates among young children have been halved since 1990, but these dramatic declines have not been mirrored in the second or third decade (see Annex 1). Furthermore, many children who survive do not thrive.[3] Previous declines in maternal mortality had already stagnated before the Covid-19 pandemic and efforts to reduce maternal mortality must be redoubled.Importantly, the crucial gains in reducing infant, child and adolescent mortality and morbidity over the past decades are potentially reversible. Examples include the recurrence of measles outbreaks whenever vaccination coverage fell,[4] and substantial increases in mental health disorders among adolescents, during the Covid-19 pandemic;[5] rapid increases in young child deaths from diarrhoea and pneumonia during conflicts;[6] and increases in vector-borne diseases due to climate change.[7] The costs of recouping ground that is lost can be substantial.
  3. Human capital development and the returns on investment
    The importance of investing in MNCAH&W is not limited to the immediate burdens of mortality and disability described above. Behaviours adopted during childhood and adolescence have profound and often life-long implications for future adult health and well-being, including productivity and life satisfaction.[8]Investing in the health and well-being of women, children and adolescents strengthens the human capital of a country, and hence the country’s wealth, potential for future development, and for ending extreme poverty and ability to create more inclusive societies.[9],[10],[11]The lifelong benefits from investing in early child development are well-recognised, including by the G20.[12], [13] The G20-supported Nurturing Care Framework[14] has influenced policies and programmes in numerous countries.[15] More recently, excellent returns on investment in adolescent health and well-being have also been demonstrated with economic returns of $5-10 for every dollar invested for most packages of “best-buy” interventions, and ratios well above 10 for some interventions.[16],[17]
  4. Effective interventions and delivery systems existThere is strong evidence that specific interventions and combinations of interventions can be effective and there are increasing examples of successful programmes at the national level. These have been summarised in WHO’s compendium of essential interventions for universal health coverage[18] and can be effectively implemented at scale through primary health care systems.
  5. Impacts of the Covid-19 pandemic, the climate crisis, and conflictThe Covid-19 pandemic has had particularly detrimental effects on children, adolescents and mothers. For example, the coverage of immunisation services fell dramatically from 2019 to 2020 and 2021.[19] The closure of schools and higher education institutions resulted in millions of children, adolescents and youth missing out on face-to-face education,[20] affecting the poorest students the worst.[21] The mental health of caregivers was impacted.[22] Targeted initiatives and investments will be needed to offset these effects.The climate crisis is also negatively affecting women, children and adolescents, with long-term consequences across the life course, and it is today’s children and young people who will bear the future impacts of the climate crisis. There will be direct impacts of heat, drought and floods on their health and nutrition, schooling and educational attainment, security and safety. Indeed, climate change is already leading to displacement and migration, family disruption, and is eroding adolescent resilience due to feelings of anxiety, fear, powerlessness, apathy, and disillusionment.[23],[24]Conflict disrupts all aspects of life. While it is commonly young men directly engaged in fighting, those who often bear the greatest burden from conflict’s indirect effects on food, health, education and social protection systems are the women, children and adolescents. It is estimated that half of childhood mortality occurs in settings affected by conflict and humanitarian needs.[25]
  6. Opportunities and risks of the digital transformationThe world is going through a rapid digital transformation.[26] The opportunities and risks of the digital transformation are particularly important for children and adolescents, and it is already having important implications for the ability of mothers to work from home.

    Women, children, and adolescents at the centre of policies and programmes    In designing and implementing programmes to respond effectively to these challenges, there is an increasing realisation of the need to put the women, children and adolescents at the centre of programmes. Moreover, a multisectoral, holistic, systems-based approach must be used, considering all the dimensions of their well-being.10,[27],[28] To do so, it will be essential for policymakers and programme implementers to meaningfully engage with women, children and adolescents and their families.[29]Although much remains to be done, increasingly, progress in MNCAH&W is being monitored. However, important data gaps remain, even within G20 countries, with initiatives such as the Global Action for Measurement of Adolescent health (GAMA) group making recommendations for how these gaps should be filled.[30]

    Accelerating progress to achieve the SDGs for women, children and adolescents    The 2022 report of the Global Strategy for Women’s, Children’s and Adolescents’ Health, a framework developed and launched in 2015 by the United Nations Secretary-General as a roadmap for promoting the health and well-being of women, children, and adolescents worldwide and achieving the Sustainable Development Goals (SDGs)[31] documents that across the globe, many countries are not on-target to meet the SDGs that relate to MNCAH&W and that the combination of the Covid-19 pandemic, the climate crisis, and geopolitical conflicts are causing the reversal of many of earlier gains.[32] Although these reversals have been most severe in the poor and fragile states, they have also occurred among the marginalised populations in most UMICs and HICs.[27]

2. The Role of the G20

As a platform for international economic cooperation, the G20 has a critical role to play in addressing the challenges to MNCAH&W. Accounting for around 80 percent of global GDP and nearly 60 percent of the global population,[33] the G20 countries’ policies and actions can impact health and well-being outcomes worldwide both through direct improvements in their own country, through national leadership and trailblazing; and through development assistance.[34] The G20, therefore, is critical to achieving the 2030 Agenda. Since its establishment in 1999, the G20 has increasingly prioritised health in its agenda, but, to date, has not directly addressed the issue of MNCAH&W in a comprehensive manner.

G20’s leadership in the health agenda

The establishment of the G20 Health Working Group (HWG) in 2017 presented an opportunity to develop a shared international agenda on key health and nutrition-related policy issues. Since then, the HWG has been actively involved in addressing various health issues, including those related to maternal and child health.[35] In 2018, the G20 Health Ministers adopted a joint statement that recognised the need to address the social determinants of health and improve health literacy, particularly among women, children, and adolescents.[36] In the same year, the Development Working Group of the G20 launched the Initiative for Early Childhood Development. The initiative promotes a life-course approach and advocates for a multisectoral strategy to improving outcomes for children.[37], [38]

In 2019, the G20 Leaders’ Declaration at the Osaka Summit reiterated the G20’s commitment to improving global health and called for strengthening health systems, including the promotion of universal health coverage. The declaration also recognised the need to address the health and well-being of women, children, and adolescents, particularly through improving access to quality health services and promoting gender equality.[39]

In 2021, the Health Ministers’ Meeting focused on the Covid-19 pandemic and its impact on global health. The G20 Health Declaration adopted at the meeting emphasised the need for global cooperation, solidarity and innovation to address the pandemic and build more resilient health systems. The G20 also further committed to promote the equitable distribution of vaccines and strengthening health systems to address future health emergencies.[40], [41]

The Government of India has identified Universal Health Coverage and improving healthcare service delivery as an important issue among the health priorities[a] for their G20 Presidency in 2023 and has proposed several initiatives for digital health innovation and solutions including the development of a global health data platform, the promotion of digital health technologies, and the establishment of a G20 health task force.[42] India’s presidency provides an opportunity to take a major step forward in the G20’s commitments to women’s, children’s, and adolescents’ health and well-being.

Strengthening policies and investments for women’s, children’s, and adolescents’ health and well-being

Despite the G20’s recognition of the importance of investing in women’s, children’s, and adolescents’ health and well-being, there are many challenges to effectively addressing their contextual needs including the lack of adequate funding for targeted health programmes. Many G20 countries have limited budgets for health and well-being programmes, and funding for women’s, children’s, and adolescents’ health and well-being is often low on the priority list. Another challenge is the lack of access to healthcare services, particularly in low-income (LICs) and middle-income countries (MICs). Many women, children, and adolescents do not have access to basic healthcare services, including maternal and child health services, adolescent health and/or school health services, age-appropriate sexual and reproductive health services, and mental health services.

3. Recommendations to the G20

  1. Sustained and enhanced funding: The G20 should prioritise sustained and enhanced funding for MNCAH&W aimed at strengthening health systems, improving access to essential health services, and addressing social determinants of health, such as poverty and gender inequality. The G20 should also prioritise investments in research and development for new and improved health technologies and vaccines. Putting emphasis on MNCAH&W is consistent with the Government of India’s G20 priorities of the prevention of, preparedness for, and response to health emergencies; promoting access to, and availability of safe, effective, high quality, affordable vaccines, therapeutics and diagnostics; and developing digital health innovations and solutions to aid universal health coverage and improve healthcare service delivery. Key opportunities for the G20 leaders to demonstrate their continued commitments for this issue will be the SDG Summit in September 2023,[43] the Global Forum for Adolescents scheduled for 11 and 12 October 2023,[44] and the Summit of the Future in 2024[45] which will have a focus on the first two decades of life. The G20 should be key in promoting, shaping and supporting both the Global Forum and the Summit.
  2. Multisectoral, holistic, systems-based approach: The G20 should adopt a multisectoral, holistic, and systems-based approach to improve health outcomes for women, children, and adolescents. This approach should include investments in digital health innovations to improve access to essential health services, especially in rural and underserved areas. The G20 should continue to prioritise investments in medicines, including research and development, to ensure universal access to life-saving drugs and vaccines. The G20 should take a life-course approach to all their programming, recognising that problems at each stage of an individual’s life can have negative effects at later stages (e.g., lack of proper nutrition and physical activity; abuse and neglect; mental ill health); and conversely, interventions across the life course can reinforce each other (e.g., nurturing care; and dietary improvements). In light of the post-Covid-19 recovery efforts aimed at fortifying national health systems and sustaining development assistance via continued leadership and contributions to multilateral and global initiatives, the G20 countries should prioritise the following actions:
    • Increase investment in primary healthcare, with a focus on MNCAH&W services;
    • Develop and implement digital health solutions, including telemedicine and e-health platforms, to improve access to essential healthcare services and information;
    • Promote equitable access to comprehensive package of services, including adopting and implementing Universal Health Coverage (UHC) policies and strategies that prioritise MNCAH&W services; and invest in the implementation of policies and programmes that address the social determinants of health, including poverty reduction and education programs, and policies that promote gender equality;
    • Strengthen and build resilient health systems that can withstand health shocks by investing in preparedness and response to health emergencies, and improving health surveillance systems and response capacities;
    • Establish cross-sectoral collaboration, and coordination including inter-Ministerial action across health, education, social protection, finance, and others to ensure budgetary alignment for programmes and services impacting MNCAH&W and ensure that multiple sectors are held accountable for achieving health-related targets and MNCAH&W outcomes by establishing clear performance indicators and reporting mechanisms; and
    • Improve multilateral coordination and cooperation to promote knowledge-sharing, resource mobilisation, and collective action for strengthening global health governance and enhancing collaboration across multiple sectors and industries for improved global health outcomes.
  3. Strengthen data systems for monitoring and implementation of policies and programmes: The G20 should prioritise investments in robust data systems for monitoring and implementation of policies and programmes for women’s, children’s, and adolescents’ health and well-being. This includes investments in digital data solutions and data interoperability to improve data collection, analysis and sharing. The G20 should also prioritise investments in capacity building and training to strengthen health information systems and equip healthcare workers with skills to ensure data quality and accuracy. This includes supporting the development of digital health innovations that enable real-time monitoring of health outcomes and health system performance.
  4. Include women’s, children’s and adolescents’ health and well-being as a recurring agenda within the Finance Track and the Sherpa Track of the G20: The G20 should ensure that women’s, children’s, and adolescents’ health and well-being is a recurring agenda item within the G20 discussions in the Finance Track and the Sherpa Track of the G20. This includes engaging stakeholders from civil society, academia, United Nations agencies, development partners and the private sector to ensure that policies and programmes are informed by the latest evidence and good practices. The G20 should also establish a dedicated working group on MNCAH&W to implement this ambitious agenda. Furthermore, the G20 should work towards establishing and strengthening partnerships to help leverage resources, promote innovation, and ensure accountability for progress towards achieving MNCAH&W goals.
  5. Meaningful engagement of women, children, and adolescents: Lastly, it is essential that women, children, and adolescents are actively engaged in policy development and decision-making processes related to their health and well-being. The G20 should prioritise their meaningful engagement through consultative efforts when making policy decisions. This includes establishing mechanisms to create an enabling environment for actively involving women’s, children’s, and adolescents’ organisations, networks, and representatives through regular dialogues and engagement sessions; providing opportunities for them to share their lived experiences, ideas, and recommendations directly with G20 leaders; and leveraging existing engagement groups, where possible (for example, Civil 20, Women 20 and Youth 20) and establish new groups where required (for example, Children 20 and/or Adolescents 20) to support participatory discussions, receive policy recommendations, and ensure that their contributions regarding their health and well-being shape the G20 agenda.

Attribution: Flavia Bustreo, Anshu Banerjee, David A. Ross, Thahira Shireen Mustafa, Oommen C. Kurian and Anshu Mohan, “Maternal, Newborn, Child and Adolescent Health and Well-Being: A Critical Agenda for the G20,” T20 Policy Brief, May 2023.

 The authors thank Bernadette Daelmans (WHO), Kathleen Strong (WHO), Chiara Servili (WHO), Lisa Rogers (WHO), Theresa Diaz (WHO) and Lori McDougall (PMNCH) for their contributions.

ANNEXURE 

Annex 1. The burden of disease and injury and the demographic and epidemiological transition: Further information

The burden of disease and injury during the first two and a half decades of life in the G20

As mentioned in the policy brief, one of the major global achievements of recent times is that mortality rates among young children (under-five years) have been halved since 1990 (Table A1). Although global mortality rates have declined among older children, adolescents and youth, these declines have not been as great in the second or third decade.[A[46], A[47], A[48]]

The G20 countries span those with very low to those with moderately high mortality burdens in these age groups (Figure A1).[A[49]] Among the under-fives, as mortality rates decrease, congenital anomalies make up a greater proportion of under 5 deaths; infectious diseases, and especially acute respiratory infections, diarrhoea and tuberculosis along with preterm birth, birth asphyxia/trauma and sepsis are the leading causes for high mortality countries within the G20 (Figure A2).[A1,A2] The causes of death among older adolescents in 19 of the G20 countries are shown in Figure A3.[A1,A2] It can be seen from this that as older adolescent mortality rates decline, injuries and self-harm become the leading killers, whereas for G20 countries with higher adolescent mortality the causes vary more, but communicable diseases (especially tuberculosis and HIV/AIDS in some countries) and interpersonal violence and unintentional injuries (especially road traffic injuries) are prominent.

While mortality has been declining at different rates across the first two and a half decades of life, burdens from morbidity and the disability it causes have been largely stagnant, so the overall proportion of the burden of disease and injury due to morbidity and disability has increased.  Figure A4 [A1, A2] which displays the causes of disability among children under five years of age within 19 of the countries of the G20, shows that, as the mortality burden decreases in this age group from left to right in the figure, the proportion of the burden due to disability caused by protein-energy malnutrition decreases, whereas that due to congenital anomalies increases. Disability due to newborn conditions (preterm birth, birth trauma and sepsis), diarrhoea and asthma is important in all or almost all the countries. Turning to disability In older adolescents (15-19 years), Figure A5 shows that, across 19 countries in the G20, higher mortality countries have greater proportions of their burden of disability from infectious diseases and iron deficiency anaemia, whereas the proportion of the disability burden due to injuries increases in lower mortality countries.[A1,A2] Mental health and substance use disorders are leading causes of disability in this age group across all 19 countries.

The demographic transition related to mortality is demonstrated across the G20 countries (Figure A1). The probability of dying within the first 28 days of life is higher than the probability of dying either during post-neonatal infancy or between first and fifth birthdays in all 19 G20 countries included in Figure A1, except South Africa and Japan. However, there is a particularly strong gradient in neonatal and post-neonatal mortality between countries with the highest under-five mortality and those country with the lowest. In all 19 countries the probability of dying between the fifteenth and 20th birthdays are higher than in the 5-9 years and 10-14 years age groups which have fairly similar, relatively low death rates (Figure A1). Similar patterns are seen for the overall burden of disease and injury measured by disability-adjusted life years (DALYs) lost (Figure A6).

The epidemiological transition across the G20 countries emphasises the increasing importance of mental health and substance use disorders, injuries and noncommunicable diseases, such as congenital anomalies and asthma, while communicable diseases (especially acute respiratory infections, diarrhoea and tuberculosis in young children and tuberculosis and HIV/AIDS in some countries in adolescents) decrease, though still remain important. Congenital anomalies,[A[50]] preterm births,[A5] mental health and substance use disorders,[A[51]] anaemia[A[52]] and interpersonal violence[A[53]], unintentional injuries[A[54]] and self-harm/suicide[A[55]] are priorities across all G20 countries (Figures A7 and A8).

The largest reductions in mortality have been from communicable diseases, though they remain an unfinished agenda (Table A2)[A[56], A[57]], especially since mortality from most communicable diseases is preventable. The reductions in the burden from communicable diseases have increased the relative importance of non-communicable diseases, including premature births, congenital anomalies, anaemia, mental health disorders and of violence, unintentional injuries and self-harm, including suicide.  It has also increased the proportion of the burden of disease and injury due to illness and disability.

Table A1. Global mortality rates (0-24 years) and their declines and proportions of deaths, by age [A3]

Age Mortality Rate, 2021 Decline in mortality rate (%) 1990-2021i Proportion of all deaths before age 25 years (%), 2021ii
Newborns (0-27 days) (deaths/1000 livebirths) 18 52 33
1-59 months (deaths/1000 population entering the age range) 21 64 38
5-9 years (deaths/1000 population) 3 70 7
10-14 years (deaths/1000 population) 3 40 5
15-19 years (deaths/1000 population) 5 38 8
20-24 years (deaths/1000 population) 6 33 10

 

Key:   i Approximate because of rounding in the data

ii Percentages do not add up to 100% because of rounding

Table A2. Global mortality during the first 25 years of life, by major groups of causes of death, 2019[A11, A12]

Cause of death Under 5 years (%) 5-24 years (%)
Communicable, maternal, perinatal, and nutritional conditions 72.3 38.5
Injuries 5.0 32.9
Noncommunicable diseases (including congenital anomalies and mental health) 22.5 28.6

 

 

Figure A1: Probability of dying by age in 19 Member States of the G20

h

Figure A2: Proportional mortality for children under-5 years by cause in 19 Member States of the G20

 

Figure A3: Proportional mortality for adolescents 15 to 19 years by cause in 19 Member States of the G20

Figure A4: Proportional disability (years of healthy life lost due to disability (YLDs)) in children under-5 years in 19 Member States of the G20

Figure A5: Proportional disability (years of healthy life lost due to disability (YLDs)) in 15–19 year-olds in 19 Member States of the G20

Figure A6: Burden of disease and injury (disability-adjusted life years (DALYs) lost) in 19 Member States of the G20, by age

Figure A7: Proportional burden of disease and injury (disability-adjusted life years (DALYs) lost) by cause in under-5 year-olds in 19 Member States of the G20

Figure A8: Proportional burden of disease and injury (disability-adjusted life years (DALYs) lost) by cause in 15–19 year-olds in 19 Member States of the G20

Endnotes

[a] Government of India’s health priorities for the G20 Presidency in 2023 include: 1) Health Emergencies Prevention, Preparedness and Response (with focus on One Health & AntiMicrobial Resistance); 2) Strengthening Cooperation in Pharmaceutical Sector with focus on Access and Availability to safe, effective, quality and Affordable Medical Countermeasures (Vaccines, Therapeutics and Diagnostics); and 3) Digital Health Innovations and Solutions to Aid Universal Health Coverage and Improve Healthcare Service Delivery.

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