A crisis of accountability for women's, children's, and adolescents' health

Even before the COVID-19 pandemic, global progress towards the 2030 Every Woman Every Child (EWEC) Global Strategy for Women's, Children's and Adolescents' Health targets to save the lives of women and children was already lagging by around 20%.¹ Now, the global pandemic is making a bad situation even worse, as some countries divert resources away from essential services.

The direct and indirect effects of the COVID-19 response on pregnant women, newborn babies, young children, and adolescents are huge. In many places, essential health services for these populations, as well as social and financial support, have been insufficient.¹ There have been mass closures of sexual and reproductive health services, including HIV testing and post-abortion care, and supply shortfalls, including for contraceptives.² Constraints in accessing maternal health services during lockdowns are compounded by health workers being diverted from maternity services to COVID-19 units.³ Immunisation campaigns have been halted, leaving an estimated 13·5 million children unprotected against life-threatening diseases.⁴ With school closures, 370 million children are missing out on school meals⁵ and adolescents are suffering from social isolation and mental health problems.⁶ And domestic violence has increased, with many more emergency calls reported in several countries.⁷

Tragically, predictions for the immediate future are even worse. Deaths among pregnant women and young children could increase by 8–45% over what would have been expected without the pandemic.⁸ Even a 10% decline in contraceptive use could lead to 15 million more unintended pregnancies in a year.⁹ For every 3 months of lockdown, 15 million more cases of gender-based violence are anticipated. And an estimated 71 million people could be pushed into extreme poverty,¹⁰ with women, children, and adolescents disproportionately affected, particularly by difficulties in accessing financial and social support.11, 12

These appalling estimates emphasise how essential it is that we, as a global community, understand how and why we are failing women, children, and adolescents, and discover the means to protect them, not only during this pandemic, but to 2030 and beyond.

4 years ago, the UN Secretary-General mandated the Independent Accountability Panel (IAP) to provide a transparent review of progress towards the implementation of the EWEC Global Strategy for Women's, Children's and Adolescents' Health.¹³ The IAP's 2020 report, Caught in the COVID-19 Storm: Women's, Children's, and Adolescents' Health in the Context of UHC and the SDGs,¹ published on July 13, 2020, shows where progress is lagging and action is needed to get back on track.

The key is accountability. World leaders must fulfil their commitments to universal health coverage,¹⁴ primary health care,¹⁵ and the International Health Regulations,¹⁶ which were urgently needed before COVID-19, and are now even more important.

In the IAP report¹ we developed and analysed country scorecards by income category and key indicators for EWEC and the Sustainable Development Goals (SDGs), which show that all countries can achieve big improvements by using resources more effectively.¹⁷ How money is spent is as important as how much is spent. Inefficiencies and corruption drain resources, meaning that globally 20–40% of health expenditure is wasted18, 19, 20—ie, about US$2 trillion a year that could be used to improve health and for sustainable development.

Countries must collect comprehensive, meaningful data, and invest according to the evidence. Yet, too many countries do not gather even the most basic information²¹—eg, one in four children younger than 5 years (166 million) are not registered with a civil authority.²² As a result, governments cannot identify all people who need help.

There is a projected shortfall of 18 million health workers worldwide.²³ But investment is needed not only in health care, but also in education, water, sanitation, and clean energy, as multisectoral factors have an equally important role in improving the health of women, children, and adolescents. Gaping inequities between and within countries disproportionately affect them.11, 12

To meet all these challenges, the IAP reiterates and renews the call for accountability to drive progress and realise rights of women, children, and adolescents. The IAP sets out an accountability framework with four pillars: commit, explain, implement, progress (panel ). Each pillar must be present for effective accountability—if only one of them is missing, the whole accountability structure falls.¹ On the basis of these four pillars, the IAP report gives three main recommendations as to how countries and other stakeholders can strengthen accountability and achieve goals.¹

Panel. Four pillars of the IAP's accountability framework.

Each pillar must be present for effective accountability.

• •Commit: all those who make commitments and have a responsibility to act should be clear on and commit to their roles and obligations towards achieving agreed goals and rights.
• •Justify: decisions and actions related to commitments must be supported and explained on the basis of evidence, rights, and the rule of law.
• •Implement: core accountability functions of Monitor–Review–Remedy–Act¹² should be institutionalised and implemented in a constructive way to facilitate learning and progress.
• •Progress: continuous progress towards agreed goals and rights should be ensured, justifying any reversals—this is the human rights principle of progressive realisation.²⁴

First, governments should invest in data systems to ensure births and deaths are registered, to monitor the quality and equity of service coverage, and for research that accounts for gender-specific and age-specific considerations. Private sector and academia should drive innovation and create demand for information, products, and services that respond to people's needs and experiences. Media and public interest organisations should support evidence gathering, and translate it into easily understood information to encourage public debate and action.

Second, accountability must be institutionalised, with a formal relation between monitoring, review, and recommendations and the remedy and action that follow. Voluntary arrangements are not good enough. All features must be fully operational and integrated in institutions and societies. Only then will countries learn from their experiences during major challenges such as COVID-19, change course, and ensure funds are invested for greatest impact.

Finally, accountability must be democratised so that the voices of people and communities are heard and acted on. We have seen how important public engagement is during the COVID-19 pandemic, when sustained criticism and protests about health workers without personal protective equipment, children missing out on school meals, and racial discrimination have forced decision makers to take action. In the country case studies that informed the IAP report, participants challenged the effectiveness of governments: “We tend to re-engineer policies instead of implementing the ones we already have”, said one participant in Kenya. Others called for more meaningful dialogues and regular communication on progress for health and rights. An overarching conclusion from many was that “voice does not equate to accountability if there is no one to listen, act, and respond”. Countries must learn from criticisms, while parliaments must hold governments to account for acknowledging and meeting people's needs. The media, civil society organisations, and social networks also have a role to play in conveying people's experience.

The IAP's recommendations offer a template for all SDGs, and particularly for those that have the most impact on women, children, adolescents, and others being left behind. Unless the world acts, the accountability crisis will persist. Accountability is a must-have, not a nice-to-have, and must be permanently embedded so that every leader and every government is obliged to do what they say they will, with citizens able to participate fully and voice their experiences.

It is always the most vulnerable who get forgotten and left behind. But if the global community genuinely achieves a strong culture of accountability, we will be so much better placed to achieve the SDGs and finally realise the rights of every woman, child, and adolescent.