that dialogue is to demonstrate an awareness of fiscal Figure 2.12 constraints to establish credibility by generating and nd Trends in index of globalization, by region and globally, 1990-2012 using evidence to show that we can make efficient use of AFR■AR■ SEAR EUR■EMR■ WPR High-income OECD■Gbal resources to deliver optimal services. To deliver, in other words, "more health for the money".55 Globalization and trade In the past few decades and in all parts of the world there has been an increase in global economic, financial, 3o political and social integration and cooperation, as attested by the KoF index of globalization, which combines a set 1995 2000 2005 of relevant economic, social and political indicators in a index on a scale of o to 100( Figure 2.12) to steer and regulate, but it is now difficult to imagine High-income OECD countries have experienced the highest significant progress on issues of global importance, such as levels of globalization, and the african Region and Eastern health, food security, sustainable energy and climate change Mediterranean Region the lowest mitigation, without the private sector playing an important role. Similarly, in low-income countries, resource flows Increasing global economic integration is associated with from foreign direct investment and remittances far outstrip the development of global forms of governance related to development support and, in the case of remittances, have trade and intellectual property as well as transnational often proved to be more resilient than aid in the face of an standards and actions in the political, social, human rights economic downturn and environmental spheres. Globalization comprises among other things, growing integration of markets and Globalization also has implications for epidemiology nation states, receding geographical constraints on social notably by facilitating the spread of communicable diseases and cultural arrangements, broader dissemination of ideas and associated risks due to increased movement of people and technologies, growing threats to national sovereignty and goods around the globe- for example through by transnational actors and the transformation of the international travel and migration and trade imals economic, political and cultural foundations of societies. and goods. In addition, the globalization of markets(and marketing) supports the spread of NCDs by changing diets Globalization has both positive and negative implications and lifestyles. Globalization may also have mixed impacts for global health. It is likely that the growth in world trade on health and health systems. For instance, low-income has also led to job and income growth, and has stimulated countries may lose health workers, but globalization may the growth in labour-intensive sectors of developing enable faster, coordinated action against health threats country economies that have been responsible for much of the progress in poverty reduction On the other hand, The World Trade Organization(WTO) was established global connectedness helped spread the impact of the in 1995 to govern global trade, including areas that have global financial and economic crisis of 2008-2009 to direct and indirect implications for public health. Around countries that had nothing to do with it. Many governments the same time, the emerging agreement on Trade related underwent expenditure contractions, which dragged down Aspects of Intellectual Property Rights(TRIPS)established economic growth prospects and cast doubts on the ability minimum standards of protection for each category of of markets to generate new and decent jobs. 9 In 2014, property rights and stimulated debate on pharmaceutical 201 million people were unemployed worldwide: this is 31 patents. In 2001, the Doha Ministerial Declaration on the million more people than before the global crisis in 2008. TRIPS Agreement and Public Health granted increased Global unemployment is expected to continue to increase flexibility for Member States to take measures to protect by 3 million in 2015 and another 8 million over the next public health and four years.60 Youth unemployment is a matter of particular circumstances e promote access to medicines in certain concern(see also the section on population trends in this chapter), and prominent in SDG 8 on sustained inclusive In 2003, the World Health Assembly expressed concerns growth and employment about access to medicines in developing countries and the plications of the current patent protection system, and The new century has also seen a transformation in the urged Member States to adapt national legislation to exploit relative power of the state on the one hand, and markets, the flexibilities contained in the tRiPs agreement. In 2004 civil society and social networks of individuals on the other. Member States were further encouraged to ensure that The role of the private sector as an engine of growth and bilateral trade agreements take into account the flexibilities innovation is not new, often transcending borders through contained in the WTO TRIPS Agreement as recognized by multinational companies. Governments retain the power the Doha Declaration ECONOMIC, SOCIAL AND ENVIRONMENTAL CONTEXT OF HEALTH
that dialogue is to demonstrate an awareness of fiscal constraints to establish credibility by generating and using evidence to show that we can make efficient use of resources to deliver optimal services. To deliver, in other words, “more health for the money”.55 Globalization and trade In the past few decades, and in all parts of the world, there has been an increase in global economic, financial, political and social integration and cooperation, as attested by the KOF index of globalization, which combines a set of relevant economic, social and political indicators in a synthetic index on a scale of 0 to 100 (Figure 2.12).56,57 High-income OECD countries have experienced the highest levels of globalization, and the African Region and Eastern Mediterranean Region the lowest. Increasing global economic integration is associated with the development of global forms of governance related to trade and intellectual property, as well as transnational standards and actions in the political, social, human rights and environmental spheres. Globalization comprises, among other things, growing integration of markets and nation states, receding geographical constraints on social and cultural arrangements, broader dissemination of ideas and technologies, growing threats to national sovereignty by transnational actors and the transformation of the economic, political and cultural foundations of societies. Globalization has both positive and negative implications for global health. It is likely that the growth in world trade has also led to job and income growth, and has stimulated the growth in labour-intensive sectors of developing country economies that have been responsible for much of the progress in poverty reduction. On the other hand, global connectedness helped spread the impact of the global financial and economic crisis of 2008–2009 to countries that had nothing to do with it. Many governments underwent expenditure contractions, which dragged down economic growth prospects and cast doubts on the ability of markets to generate new and decent jobs.59 In 2014, 201 million people were unemployed worldwide; this is 31 million more people than before the global crisis in 2008. Global unemployment is expected to continue to increase by 3 million in 2015 and another 8 million over the next four years.60 Youth unemployment is a matter of particular concern (see also the section on population trends in this chapter), and prominent in SDG 8 on sustained inclusive growth and employment. The new century has also seen a transformation in the relative power of the state on the one hand, and markets, civil society and social networks of individuals on the other. The role of the private sector as an engine of growth and innovation is not new, often transcending borders through multinational companies. Governments retain the power to steer and regulate, but it is now difficult to imagine significant progress on issues of global importance, such as health, food security, sustainable energy and climate change mitigation, without the private sector playing an important role. Similarly, in low-income countries, resource flows from foreign direct investment and remittances far outstrip development support and, in the case of remittances, have often proved to be more resilient than aid in the face of an economic downturn.61 Globalization also has implications for epidemiology, notably by facilitating the spread of communicable diseases and associated risks due to increased movement of people and goods around the globe – for example, through international travel and migration and trade in animals and goods. In addition, the globalization of markets (and marketing) supports the spread of NCDs by changing diets and lifestyles. Globalization may also have mixed impacts on health and health systems. For instance, low-income countries may lose health workers, but globalization may enable faster, coordinated action against health threats. The World Trade Organization (WTO) was established in 1995 to govern global trade, including areas that have direct and indirect implications for public health. Around the same time, the emerging agreement on Trade Related Aspects of Intellectual Property Rights (TRIPS) established minimum standards of protection for each category of property rights and stimulated debate on pharmaceutical patents. In 2001, the Doha Ministerial Declaration on the TRIPS Agreement and Public Health granted increased flexibility for Member States to take measures to protect public health and promote access to medicines in certain circumstances.62 In 2003, the World Health Assembly expressed concerns about access to medicines in developing countries and the implications of the current patent protection system, and urged Member States to adapt national legislation to exploit the flexibilities contained in the TRIPS Agreement. In 2004, Member States were further encouraged to ensure that bilateral trade agreements take into account the flexibilities contained in the WTO TRIPS Agreement as recognized by the Doha Declaration. KOF index of globalization 1990 2015 70 60 50 40 30 Figure 2.12 Trends in index of globalization, by region and globally, 1990–20123,58 2000 2005 2010 20 AFR AMR SEAR EUR EMR WPR High-income OECD Global 1995 80 ECONOMIC, SOCIAL AND ENVIRONMENTAL CONTEXT OF HEALTH 27
The main outcome of these various initiatives and Domestic spending- both government and private discussions was a significant drop in the price of certain also increased substantially and, despite growing more drugs. For example, the 100-fold reduction in the price of slowly than development assistance for health, remain antiretroviral medicines against HIV/AIDS since 2000 and the dominant source of health financing even in low- the global effort to increase access to such therapies, notably income countries, where it represented 75% on average in sub-Saharan Africa, was made possible by the successful in 2013. This growth in domestic spending was facilitated mplementation of the TRIPS Agreement, including the by continued strong economic growth in most low-an production of much cheaper but nevertheless high-quality middle-income countries despite the economic crisis. generics(see Chapter 5). However, the failure to complete the Doha Round, and the increase in mega-regional trade Nevertheless, total health spending from domestic and agreements such as the Trans-Pacific Partnership(TPP) external sources combined remained below a proposed and European Union-United States agreements, could target of US$ 86 per capita65 in 39 countries in 2013, and strengthen intellectual property protection in ways that included six countries that spent less than US$ 20 could undermine access to medical products capita. boN the other hand, the dependence of health systems on out-of-pocket spending has also fallen during Within the SDG health goal, Target 3. b reiterates the this period. At the population-level, this facilitates peoples importance of access to affordable essential medicines ability to use needed health services and reduces financial and vaccines, in accordance with the doha Declaration catastrophe and impoverishment. However, this spending on the TRIPS Agreement and Public Health. Reducing the remains high for many individuals in many countries, so still costs of essential medicines, vaccines and technologies in constitutes a barrier to access for many and poses a risk developing countries continues to be a major priority as of impoverishment and long-term financial problems for globalization and trade liberalization continue those who do get care Development assistance for health The contributions from public-private partnerships, such GAVI and the Global Fund, and nongovernmental Much of the improvement in the availability an organizations(including foundations) have expanded. 6t of services and in health and development outco This has brought in new funding, while also supporting since 2000 was facilitated by a substantial increase in innovative approaches and the large-scale introduction development financing, including for health. In 2013, of new technologies into routine systems at affordable total health spending reached US$ 7. 3 trillion, more than prices; but it has also focused resources on vertical double the amount spent in 20006 and the increase in disease programmes, in some instances unbalancing and development assistance for health has been one of the fragmenting health systems, leaving multiple gaps such features of the MDG era. Disbursements for development as weak disease surveillance and response systems-as assistance for health tripled after 2000( Figure 2.13), were exposed by the recent Ebola epidemic in West africa growing at a faster rate than domestic health spending, -or inadequate resources to meet the rapidly growing although the rate of growth has slowed since the financial NCD epidemic. crisis of 2008-2009. This external financial support for health was targeted particularly at initiatives related to the The Sdgs present an opportunity for a shift in emphasis three health goals highlighted in the MDGs, representing away from the funding of vertical programmes towards n estimated 61% of all development assistance for health more system-wide, cross-cutting support, consistent with disbursed from 2000 to 2014 the aim of UHC. For example, health Target 3 c specifically calls for efforts to"substantially increase health financing Figure 213 and the recruitment, development, training and retention Development assistance for health by health focus area, 2000-201454 of the health workforce in developing countries, especially HN/AIDs TB. malaria and other infectious diseases in least developed countries and small island developing a. newbom and child health other states". There are also multiple targets under other goals that are relevant in this context that encourage states to commit funds according to their own priorities such as Target 10. b to"encourage ODa and financial flows. including direct investment, to States where the need is greatest, in particular least developed countries, African ountries, small island developing States and landlocked developing countries, in accordance with their national 计 plans and programmes". Other references, such as Target 17.2, encourage high-income countries to maintain their 2288&22 commitment to ODA Preliminary estimates. HEALTH IN 2015: FROM MDGs TO SDGs
The main outcome of these various initiatives and discussions was a significant drop in the price of certain drugs. For example, the 100-fold reduction in the price of antiretroviral medicines against HIV/AIDS since 2000 and the global effort to increase access to such therapies, notably in sub-Saharan Africa, was made possible by the successful implementation of the TRIPS Agreement, including the production of much cheaper but nevertheless high-quality generics (see Chapter 5). However, the failure to complete the Doha Round, and the increase in mega-regional trade agreements such as the Trans-Pacific Partnership (TPP) and European Union–United States agreements, could strengthen intellectual property protection in ways that could undermine access to medical products. Within the SDG health goal, Target 3.b reiterates the importance of access to affordable essential medicines and vaccines, in accordance with the Doha Declaration on the TRIPS Agreement and Public Health. Reducing the costs of essential medicines, vaccines and technologies in developing countries continues to be a major priority as globalization and trade liberalization continue. Development assistance for health Much of the improvement in the availability and use of services and in health and development outcomes since 2000 was facilitated by a substantial increase in development financing, including for health. In 2013, total health spending reached US$ 7.3 trillion, more than double the amount spent in 200063 and the increase in development assistance for health has been one of the features of the MDG era. Disbursements for development assistance for health tripled after 2000 (Figure 2.13), growing at a faster rate than domestic health spending, although the rate of growth has slowed since the financial crisis of 2008–2009. This external financial support for health was targeted particularly at initiatives related to the three health goals highlighted in the MDGs, representing an estimated 61% of all development assistance for health disbursed from 2000 to 2014. Domestic spending – both government and private – also increased substantially and, despite growing more slowly than development assistance for health, remains the dominant source of health financing even in lowincome countries, where it represented 75% on average in 2013. This growth in domestic spending was facilitated by continued strong economic growth in most low- and middle-income countries despite the economic crisis. Nevertheless, total health spending from domestic and external sources combined remained below a proposed target of US$ 86 per capita65 in 39 countries in 2013, and included six countries that spent less than US$ 20 per capita.63 On the other hand, the dependence of health systems on out-of-pocket spending has also fallen during this period. At the population-level, this facilitates people’s ability to use needed health services and reduces financial catastrophe and impoverishment. However, this spending remains high for many individuals in many countries, so still constitutes a barrier to access for many, and poses a risk of impoverishment and long-term financial problems for those who do get care. The contributions from public–private partnerships, such as GAVI and the Global Fund, and nongovernmental organizations (including foundations) have expanded.66 This has brought in new funding, while also supporting innovative approaches and the large-scale introduction of new technologies into routine systems at affordable prices; but it has also focused resources on vertical disease programmes, in some instances unbalancing and fragmenting health systems, leaving multiple gaps such as weak disease surveillance and response systems – as were exposed by the recent Ebola epidemic in West Africa – or inadequate resources to meet the rapidly growing NCD epidemic. The SDGs present an opportunity for a shift in emphasis away from the funding of vertical programmes towards more system-wide, cross-cutting support, consistent with the aim of UHC. For example, health Target 3.c specifically calls for efforts to “substantially increase health financing and the recruitment, development, training and retention of the health workforce in developing countries, especially in least developed countries and small island developing states”. There are also multiple targets under other goals that are relevant in this context that encourage states to commit funds according to their own priorities such as Target 10.b to “encourage ODA and financial flows, including direct investment, to States where the need is greatest, in particular least developed countries, African countries, small island developing States and landlocked developing countries, in accordance with their national plans and programmes”. Other references, such as Target 17.2, encourage high-income countries to maintain their commitment to ODA. (2014 US$, billions) 40 2000 2005 2010 Figure 2.13 Development assistance for health by health focus area, 2000–201464 HIV/AIDS TB, malaria and other infectious diseases Maternal, newborn and child health Other a Preliminary estimates. 2014a 2013a 2001 2002 2003 2004 2006 2007 2008 2009 2011 2012 35 30 25 20 15 10 5 0 28 HEALTH IN 2015: FROM MDGs TO SDGs
One of the challenges we face as we move into the Sdg era is The composition of development assistance for health also the increasingly complex and fragmented institutional global needs to adapt to the rapidly changing epidemiological health landscape; and incentives that favour the creation transition away from infectious diseases towards ncd of new organizations, financing channels and monitoring and injuries, and the complex socioeconomic patterns of systems over the reform of those that already exist risk disease and risk factors that appear in different countries exacerbating tendencies to overlap, duplicate and interfere. It also needs to address emerging global threats such as antimicrobial resistance, emerging infections and climate Financing for development is also diversifying beyond change. The world must ensure that global public good ODA, and sources of development financing of growing such as health research and development for diseases that importance include funds and foundations, nongovernmental affect developing countries and the setting of global norms organizations, civil society organizations and direct giving and standards are adequately financed. 50 platforms. For instance, the contribution of philanthropic organizations to development increased by a factor of 10 Many of the worlds poorest people will remain dependent between 2003 and 2012, notably among them the bill on external financial and technical support. It is, therefore melinda Gates Foundation. In the context of the paris likely that the greatest need -as well as the focus of much Declaration on Aid Effectiveness and the Accra Agenda for traditional development finance-will become increasingly Action, health has had a combined leadership and tracer concentrated in the worlds most unstable and fragile role. It was also demonstrated, through initiatives such as countries, which are often unpopular with donors in terms the International Health Partnership and related initiatives of fiduciary risk. As a result, donors are likely to favour their (IHP+)6and Harmonization for Health in Africa, that despite own parallel systems over national ones and thus limiting the many different players, coordination around national their contribution to strengthening national capacity. This health strategies can be improved. Such approaches extend also raises important questions about how the work of beyond the Un to include bilateral development agencies, the Un in other, less poor, countries will be financed. The development banks and nongovernmental organizations, and Busan Partnership for Effective Development Co-operation, can show increases both in efficiency and in health outcomes. which was formed after the meeting on development in the Republic of Korea in 2011, signalled that a framework Global revenue flows for health financing are likely based on aid"has given way to a broader, more inclusive to continue to change 50 as the principles underlying international consensus that emphasizes partr development aid shift from an emphasis on donor-recipient approaches to cooperation, particularly South-South and relations based on financial contributions to reflect concepts triangular relationships. 0 of cooperation and partnership, involving diverse types of support and exchanges. 68 After a period of dramatic growth in development assistance since 200, i is possible that SOcIAL DEVELOPMENT More importantly, the economic growth in many low-and middle-income countries has provided, and will continue to In addition to the direct continuation of MDGs 2 and 3 provide, major opportunities for increasing domestic health in the SDGs 4 and 5, on education and gender equality vestments. Increased domestic efforts to mobilize more respectively, the SDgs also give much greater weight to government revenues and increase the priority for health human rights and to equity - particularly with Goal 10 to in public resource allocation, alongside efforts to improve reduce inequality -than was the case with the MDGs. efficiency in the use of funds, would accelerate this progress Gender equality and rights As part of the Addis ababa Action Agenda, countries agreed on a broad package of over 100 measures that Gender inequality is expressed in a variety of ways, draw upon all sources of finance, technology, innovation, including mistreatment of one sex by another, differences trade and data to support the implementation of the SDGs. in power and opportunities in society and differences in Notable among these measures are the promotion of more access to health services. Gender inequalities in education, efficient government revenue collection and a reduction in employment and civil liberties carry a cost. They not only tax avoidance and illicit financial flows. These measures deprive women of basic freedoms"and violate their human re essential for expanding the fiscal space and thus vital rights, but also negatively affect development outcomes to making progress on the health goal and targets in the for societies as a whole. Gender inequities have adverse SDGS, and in particular UHC. Strengthening domestic impacts on health, especially for women. In many countries resource mobilization in low-and middle-income countries and societies, women and girls are treated as socially should enable oda to be focused on mainly the poorest inferior. Behavioural and other social norms, codes of countries. 68 However, for other low- and some lower- conduct and laws perpetuate the subjugation of females middle-income countries, the need for external financial and condone violence against them. Unequal power assistance will not be eliminated relations and gendered norms and values translate into ECONOMIC, SOCIAL AND ENVIRONMENTAL CONTEXT OF HEALTH
One of the challenges we face as we move into the SDG era is the increasingly complex and fragmented institutional global health landscape; and incentives that favour the creation of new organizations, financing channels and monitoring systems over the reform of those that already exist risk exacerbating tendencies to overlap, duplicate and interfere. Financing for development is also diversifying beyond ODA, and sources of development financing of growing importance include funds and foundations, nongovernmental organizations, civil society organizations and direct giving platforms. For instance, the contribution of philanthropic organizations to development increased by a factor of 10 between 2003 and 2012, notably among them the Bill & Melinda Gates Foundation. In the context of the Paris Declaration on Aid Effectiveness and the Accra Agenda for Action, health has had a combined leadership and tracer role. It was also demonstrated, through initiatives such as the International Health Partnership and related initiatives (IHP+)67 and Harmonization for Health in Africa, that despite the many different players, coordination around national health strategies can be improved. Such approaches extend beyond the UN to include bilateral development agencies, development banks and nongovernmental organizations, and can show increases both in efficiency and in health outcomes. Global revenue flows for health financing are likely to continue to change50 as the principles underlying development aid shift from an emphasis on donor–recipient relations based on financial contributions to reflect concepts of cooperation and partnership, involving diverse types of support and exchanges.68 After a period of dramatic growth in development assistance since 2000, it is possible that the lower growth rates evident since 2009 will continue. More importantly, the economic growth in many low- and middle-income countries has provided, and will continue to provide, major opportunities for increasing domestic health investments. Increased domestic efforts to mobilize more government revenues and increase the priority for health in public resource allocation, alongside efforts to improve efficiency in the use of funds, would accelerate this progress. As part of the Addis Ababa Action Agenda,69 countries agreed on a broad package of over 100 measures that draw upon all sources of finance, technology, innovation, trade and data to support the implementation of the SDGs. Notable among these measures are the promotion of more efficient government revenue collection and a reduction in tax avoidance and illicit financial flows. These measures are essential for expanding the fiscal space and thus vital to making progress on the health goal and targets in the SDGs, and in particular UHC. Strengthening domestic resource mobilization in low- and middle-income countries should enable ODA to be focused on mainly the poorest countries.68 However, for other low- and some lowermiddle-income countries, the need for external financial assistance will not be eliminated. The composition of development assistance for health also needs to adapt to the rapidly changing epidemiological transition away from infectious diseases towards NCDs and injuries, and the complex socioeconomic patterns of disease and risk factors that appear in different countries. It also needs to address emerging global threats such as antimicrobial resistance, emerging infections and climate change. The world must ensure that global public goods such as health research and development for diseases that affect developing countries and the setting of global norms and standards are adequately financed.50 Many of the world’s poorest people will remain dependent on external financial and technical support. It is, therefore, likely that the greatest need – as well as the focus of much traditional development finance – will become increasingly concentrated in the world’s most unstable and fragile countries, which are often unpopular with donors in terms of fiduciary risk. As a result, donors are likely to favour their own parallel systems over national ones and thus limiting their contribution to strengthening national capacity. This also raises important questions about how the work of the UN in other, less poor, countries will be financed. The Busan Partnership for Effective Development Co-operation, which was formed after the meeting on development in the Republic of Korea in 2011, signalled that a framework based on “aid” has given way to a broader, more inclusive, international consensus that emphasizes partnership approaches to cooperation, particularly South–South and triangular relationships.70 SOCIAL DEVELOPMENT In addition to the direct continuation of MDGs 2 and 3 in the SDGs 4 and 5, on education and gender equality, respectively, the SDGs also give much greater weight to human rights and to equity – particularly with Goal 10 to reduce inequality – than was the case with the MDGs. Gender equality and rights Gender inequality is expressed in a variety of ways, including mistreatment of one sex by another, differences in power and opportunities in society, and differences in access to health services. Gender inequalities in education, employment and civil liberties carry a cost. They not only deprive women of basic freedoms71 and violate their human rights, but also negatively affect development outcomes for societies as a whole. Gender inequities have adverse impacts on health, especially for women. In many countries and societies, women and girls are treated as socially inferior. Behavioural and other social norms, codes of conduct and laws perpetuate the subjugation of females and condone violence against them. Unequal power relations and gendered norms and values translate into ECONOMIC, SOCIAL AND ENVIRONMENTAL CONTEXT OF HEALTH 29
differential access to and control over health resources, The strong relationship between the status of women and both within families and beyond. Across a range of health health forms the basis for integrated action. Actions for the problems, girls and women face differential exposures and health sector include vulnerabilities that are often poorly recognized. 2 Enhancing data and statistics: Disaggregation of key he MDgs included a gender equality goal focused on statistics by gender is critical for monitoring progress, gender disparity in education, although it also included identifying key gaps, targeting, etc, 76 including health indicators for female workforce participation and female data. This includes targets on infectious diseases (3.3) representation in parliament. The SDGs also target gender NCDs and mental health (3.4), substance abuse and equality( Goal 5) and gender equality is specifically referred harmful use of alcohol (3.5), injuries (3.6) and UHC to in several targets of other goals, including education, (3.8) economic and other rights, as well as targets related to violence against women(see Chapter 8)and sexual and Increasing access to quality health care: Comprehensive reproductive rights(see Chapter 4) strategies to target gender inequality in health care and put into practice policies to ensure equal access During the MDG era, substantial gains were been made for women, adolescents and youth to affordable and on severe ral fronts. Gender parity in school enrolment for adequate health-care services, including primary health primary education in the developing regions as a whole was are and basic nutrition reached by 2015. Women 's access to paid employment in non-agricultural sectors increased globally from 35% in Supporting caregiving roles: Approaches to strengthen 1990 to 41%in 2015, with increases, although unequal human resources for health must acknowledge the observed in almost all regions. The average proportion of critical role played by women as informal caregivers in women in parliament has nearly doubled over the past two the home and community whether it concerns HIV/AIDS decades, but still only one in five members is a woman in low-income countries or elderly care in high-income Despite these gains, much remains to be done as we countries. 2 move forward into the SDG era, as was underlined by the Commission on the Status of Women in 2015, which Eliminating harmful practices: Policies and strategic actions concluded that progress since the 1995 Beijing Declaration that transform discriminatory social norms and gender and Platform for Action had been slow and uneven, with stereotypes, and eliminate harmful practices including major gaps remaining. 7 Similar conclusions were reached by child, early and forced marriage, honour crimes and the Commission on Population and Development in a 2014 emale genital mutilation. review of the implementation of action of the International Conference on Population and Development. 4. /5 Combating violence against women: Violence against women remains a substantial obstacle to reaching gender equality, and the health sector plays a key role in violence prevention and in treating the consequences Introducing gender-sensitive policies: Improvement and strengthening of gender responsive national policies, programmes and strategies Human rights The right to the enjoyment of the highest attainable standard of physical and mental health was first articulated in the 1946 Constitution of WHo, and has been echoed in many other legally binding human rights conventions. 78, 79 In 2000, the United Nations committee on Economic social and Cultural Rights adopted a general Comment on the right to Health, stating that this right extends beyond timely and appropriate health care to the underlying determinants of health, such as: access to safe drinking-water and sanitation adequate supply of safe food, nutrition and housing; health occupational and environmental conditions; and access to health-related education and information, including sexual and reproductive health. 80 HEALTH IN 2015: FROM MDGs TO SDGs
differential access to and control over health resources, both within families and beyond. Across a range of health problems, girls and women face differential exposures and vulnerabilities that are often poorly recognized.72 The MDGs included a gender equality goal focused on gender disparity in education, although it also included indicators for female workforce participation and female representation in parliament. The SDGs also target gender equality (Goal 5) and gender equality is specifically referred to in several targets of other goals, including education, economic and other rights, as well as targets related to violence against women (see Chapter 8) and sexual and reproductive rights (see Chapter 4). During the MDG era, substantial gains were been made on several fronts. Gender parity in school enrolment for primary education in the developing regions as a whole was reached by 2015. Women’s access to paid employment in non-agricultural sectors increased globally from 35% in 1990 to 41% in 2015, with increases, although unequal, observed in almost all regions. The average proportion of women in parliament has nearly doubled over the past two decades, but still only one in five members is a woman.38 Despite these gains, much remains to be done as we move forward into the SDG era, as was underlined by the Commission on the Status of Women in 2015, which concluded that progress since the 1995 Beijing Declaration and Platform for Action had been slow and uneven, with major gaps remaining.73 Similar conclusions were reached by the Commission on Population and Development in a 2014 review of the implementation of action of the International Conference on Population and Development.74,75 The strong relationship between the status of women and health forms the basis for integrated action. Actions for the health sector include: • Enhancing data and statistics: Disaggregation of key statistics by gender is critical for monitoring progress, identifying key gaps, targeting, etc.,76 including health data.72 This includes targets on infectious diseases (3.3), NCDs and mental health (3.4), substance abuse and harmful use of alcohol (3.5), injuries (3.6) and UHC (3.8). • Increasing access to quality health care: Comprehensive strategies to target gender inequality in health care and put into practice policies to ensure equal access for women, adolescents and youth to affordable and adequate health-care services, including primary health care and basic nutrition. • Supporting caregiving roles: Approaches to strengthen human resources for health must acknowledge the critical role played by women as informal caregivers in the home and community, whether it concerns HIV/AIDS in low-income countries or elderly care in high-income countries.72 • Eliminating harmful practices: Policies and strategic actions that transform discriminatory social norms and gender stereotypes, and eliminate harmful practices including, child, early and forced marriage, honour crimes and female genital mutilation. • Combating violence against women: Violence against women remains a substantial obstacle to reaching gender equality, and the health sector plays a key role in violence prevention and in treating the consequences of violence. • Introducing gender-sensitive policies: Improvement and strengthening of gender responsive national policies, programmes and strategies. Human rights The right to the enjoyment of the highest attainable standard of physical and mental health was first articulated in the 1946 Constitution of WHO,77 and has been echoed in many other legally binding human rights conventions.78,79 In 2000, the United Nations Committee on Economic, Social and Cultural Rights adopted a General Comment on the Right to Health, stating that this right extends beyond timely and appropriate health care to the underlying determinants of health, such as: access to safe drinking-water and sanitation; adequate supply of safe food, nutrition and housing; health occupational and environmental conditions; and access to health-related education and information, including sexual and reproductive health.80 30 HEALTH IN 2015: FROM MDGs TO SDGs
Most recently, the right to health has been re-emphasized in and treatment practices. Reciprocally, good health permits terms of the achievement of UHC (see Chapter 3), while the people to fully benefit from education, while poor health SDG declaration stresses the importance of the Universal is directly associated with poor educational attainment Declaration of Human Rights (as well as other international Female education is one of the strongest determinants of instruments relating to human rights and international child survival in all societies. 86, 87,88 Female education is thus law)in a number of places, as a key underlying principle. a key strategy for ending preventable maternal and child The right to health is closely related to and dependent deaths, as well as reducing fertility and improving child, upon the realization of other human rights, as contained adult and family health and nutrition. in the International Bill of Rights, such as the right to food, housing, work and education. Human rights, including The completion of basic education is also widely regarded the right to health, are especially important for vulnerable as essential to literacy, numeracy and informed citizenship groups, such as women, migrants or people with disabilities, The participation of at least some proportion of adults at who may be more likely to face discrimination, stigma and/ the more specialized upper secondary and tertiary levels is or socioeconomic hurdles also critical for promoting individual opportunity, economic development and societal well-being. Recent evidence also People with disabilities are a particular matter of concern, shows some direct links between secondary education and often facing discrimination and barriers that restrict them health, such as protection against Hiv risk. 89 from participating in society on an equal basis. WHO estimates that about 1 billion people worldwide live with disability or impairment with a larger proportion living in Primary school completion rate by region and globally, 1990 and 201520 low-and middle-income countries. l Disability was not mentioned in the MDGs, but is implicitly included in SDG Goal 3, which is concerned with the health and well-being a for all, at all ages Disability is also specifically mentioned 80 in other targets on education (4. a), social, economic and political inclusion(10.2), sustainable cities(11. 7), and equity 360 monitoring(17.18). In addition, people with disabilities are obviously included in the UHC target, since people with disabilities are more likely to have higher health- care expenditures with higher out-of-pocket payments. 82 墨墨虽昌昌墨昌虽昌墨昌 The explicit recognition that people with disabilities EMR need to have access to appropriate health interventions, Income including interventions for rehabilitation and assistive health technologies and products, as part of the goal of moving towards UHC provides a major impetus for disability-related The mdgs contained a single target to achieve univers health initiatives primary education. Primary school net enrolment rate in developing regions reached 91% in 2015, up from 80% The main strategy going forward is to accomplish the in 1990, which means that more children than ever are objectives of the WHo Global Disability Action Plan 2014- attending primary school. However, just over half of all 2021 as agreed by all countries and implement the actions countries have achieved universal primary enrolment by required. 83, 84 The objectives of the action plan are threefold: 2015; with 10% close and the remaining 38% far or very (i) to remove barriers and improve access to health far from achieving it. This leaves 57 million children out services and programmes: (i) to strengthen and extend of school globally and almost 100 million adolescents in rehabilitation, assistive technology, assistance and support low-and middle-income countries not completing primary services, and community-based rehabilitation; and (ii) to education in 2015. A lack of focus on the marginalized has strengthen the collection of relevant and internationally left the poorest five times less likely to complete a full cycle comparable data on disability and support research on of primary education than the richest. a high and growing disability and related services. proportion of out-of-school children live in conflict-affected lt, completion rates( Figure 2.14)and th Education quality of primary education are regarded as unsatisfactory in large parts of the world.4.38 Education is strongly linked to health and other determinants of health, contributing directly and indirectly to better gender parity has been achieved at the primary level in health. 54 For example, education has an independent and 69% of countries by 2015. at the secondary level, only 48% substantial causal effect on adult mortality and morbidity &5 of countries will reach the goal. Child marriage and early and also affects health indirectly through proximate pregnancy continue to hinder girls' progress in education determinants such as nutrition, sanitation and prevention Girls remain less likely than boys to ever enter school, ECONOMIC, SOCIAL AND ENVIRONMENTAL CONTEXT OF HEALTH
Most recently, the right to health has been re-emphasized in terms of the achievement of UHC (see Chapter 3), while the SDG declaration stresses the importance of the Universal Declaration of Human Rights (as well as other international instruments relating to human rights and international law) in a number of places, as a key underlying principle. The right to health is closely related to and dependent upon the realization of other human rights, as contained in the International Bill of Rights, such as the right to food, housing, work and education. Human rights, including the right to health, are especially important for vulnerable groups, such as women, migrants or people with disabilities, who may be more likely to face discrimination, stigma and/ or socioeconomic hurdles. People with disabilities are a particular matter of concern, often facing discrimination and barriers that restrict them from participating in society on an equal basis. WHO estimates that about 1 billion people worldwide live with disability or impairment with a larger proportion living in low- and middle-income countries.81 Disability was not mentioned in the MDGs, but is implicitly included in SDG Goal 3, which is concerned with the health and well-being for all, at all ages. Disability is also specifically mentioned in other targets on education (4.a), social, economic and political inclusion (10.2), sustainable cities (11.7), and equity monitoring (17.18). In addition, people with disabilities are obviously included in the UHC target, since people with disabilities are more likely to have higher healthcare expenditures with higher out-of-pocket payments.82 The explicit recognition that people with disabilities need to have access to appropriate health interventions, including interventions for rehabilitation and assistive health technologies and products, as part of the goal of moving towards UHC provides a major impetus for disability-related health initiatives. The main strategy going forward is to accomplish the objectives of the WHO Global Disability Action Plan 2014- 2021 as agreed by all countries and implement the actions required.83,84 The objectives of the action plan are threefold: (i) to remove barriers and improve access to health services and programmes; (ii) to strengthen and extend rehabilitation, assistive technology, assistance and support services, and community-based rehabilitation; and (iii) to strengthen the collection of relevant and internationally comparable data on disability and support research on disability and related services. Education Education is strongly linked to health and other determinants of health, contributing directly and indirectly to better health.54 For example, education has an independent and substantial causal effect on adult mortality and morbidity,85 and also affects health indirectly through proximate determinants such as nutrition, sanitation and prevention and treatment practices. Reciprocally, good health permits people to fully benefit from education, while poor health is directly associated with poor educational attainment. Female education is one of the strongest determinants of child survival in all societies.86,87,88 Female education is thus a key strategy for ending preventable maternal and child deaths, as well as reducing fertility and improving child, adult and family health and nutrition. The completion of basic education is also widely regarded as essential to literacy, numeracy and informed citizenship. The participation of at least some proportion of adults at the more specialized upper secondary and tertiary levels is also critical for promoting individual opportunity, economic development and societal well-being. Recent evidence also shows some direct links between secondary education and health, such as protection against HIV risk.89 70 60 50 80 Figure 2.14 Primary school completion rate by region and globally, 1990 and 20153,90 90 AFR1990 2015 AMR 1990 2015 SEAR 1990 2015 EUR1990 2015 EMR 1990 2015 WPR 1990 2015 Highincome OECD 1990 2015 Primary school completion rate (%) 100 Global 1990 2015 40 The MDGs contained a single target to achieve universal primary education. Primary school net enrolment rate in developing regions reached 91% in 2015, up from 80% in 1990, which means that more children than ever are attending primary school. However, just over half of all countries have achieved universal primary enrolment by 2015; with 10% close and the remaining 38% far or very far from achieving it. This leaves 57 million children out of school globally and almost 100 million adolescents in low- and middle-income countries not completing primary education in 2015. A lack of focus on the marginalized has left the poorest five times less likely to complete a full cycle of primary education than the richest. A high and growing proportion of out-of-school children live in conflict-affected zones. As a result, completion rates (Figure 2.14) and the quality of primary education are regarded as unsatisfactory in large parts of the world.4,38 Gender parity has been achieved at the primary level in 69% of countries by 2015.At the secondary level, only 48% of countries will reach the goal. Child marriage and early pregnancy continue to hinder girls’ progress in education. Girls remain less likely than boys to ever enter school, ECONOMIC, SOCIAL AND ENVIRONMENTAL CONTEXT OF HEALTH 31