Jennifer J. K. Rasanathan, Benjamin Mason Meier, Kumanan Rasanathan
This week, countries will adopt the Sustainable Development Goals (SDGs) following three years of discussions on what should succeed the Millennium Development Goals (MDGs).1 To capitalize on this opportunity to further the progressive realization of every child’s right to health, we need to learn from experiences with the MDGs for child health. We must also address potential challenges with the formulation of the new goals, ensure that children’s right to health is considered broadly across the SDGs and identify the specific advantages of a rights-based approach in promoting equity and accountability to achieve the SDGs.
The MDGs set the global agenda for development, including for child health, and have been associated with an acceleration of reduction in under-5 child mortality. There has been a decrease from 12.7 million under-5 child deaths globally in 1990 to 5.9 million in 2014.2 Following a reduced global focus in the 1990s, the MDG 4 target on child mortality fostered a revitalization of political commitment and visibility, generating increased global and national resources and a range of new UN system initiatives. And yet, MDG 4 will not be met at the global level or in a majority of countries and progress has been slower for very young children, with almost half of under-5 mortality now occurring in the first month of life.3
Three key challenges can be identified with the MDGs’ impact on child health strategies. First, focusing on improvement through national averages obscured differential progress between and within countries, often ignoring increasing disparities—a trend that prompted UNICEF to refocus its work to prioritize equity and the most disadvantaged communities.4 Second, although the MDG agenda addressed social or underlying determinants of health, in practice MDG targets were pursued separately. Specific efforts toward MDG 4 emphasized health sector interventions, despite clear evidence of the importance of social determinants for child health. For example, malnutrition is the underlying cause of 45% of child deaths, and maternal education may have contributed up to a half of reduction in child mortality over recent decades.5 Third, human rights-based approaches (HRBAs)—which reinforce equity, participation, social determinants and accountability—were largely neglected in the development and implementation of the MDGs.
The SDGs present clear opportunities to address these shortcomings of the MDGs but remain vulnerable to all three. Discussions around the SDGs have focused on equity, pledging that “no one will be left behind.”6 There is a specific goal on inequality (SDG 10) and agreement that targets should only be considered achieved when all key groups within countries meet those targets. The SDGs are broader than the MDGs: they include more determinants of health, and their targets span social, political, environmental and peace pillars for sustainable development. They also seek to mainstream human rights, focusing on non-discrimination, marginalized groups and disaggregation of data for monitoring SDG indicators (which remain to be set).7
Still, calls for explicit SDG targets on closing gaps were mostly ignored. The SDGs themselves do not clearly show how action across the 17 goals will be aligned, or how human rights instruments will be incorporated in practice. While SDG 3 lists key interests for health, it lacks clear guidance on an integrated agenda or calls for action on determinants. Whereas the current draft strives “to provide children and youth with a nurturing environment for the full realization of their rights and capabilities,” a child’s right to health is not explicitly acknowledged.8 Finally, some of the language in the SDGs lacks precision, reflecting the intense country-led debates and compromises on specific wording during a participatory process—which did not occur with the MDGs.
For child health, target 3.2 institutionalizes the ambitious but achievable equity-focused agenda first laid out in A Promise Renewed, which seeks convergence of child mortality in all countries within a generation.9 While target 3.2 does not mention equity explicitly, achieving such low absolute targets in all countries (as opposed to MDG 4’s proportional target) necessarily requires reducing inequities between and within countries. Because the burden of mortality in most countries is now disproportionately concentrated in the worst off populations, these low levels of child mortality cannot be reached without prioritizing efforts involving marginalized populations and acting on social determinants. Many determinants of child health and development are represented in other SDG targets; 3.2 must be considered with the rest of the health targets in SDG 3 and in constellation with the other targets that impact child health to achieve “healthy lives for all.”
In adopting the SDGs, it is imperative to consider the political framing of their meaning as international commitments are translated into national implementation efforts for child health and social outcomes. States are obligated under human rights law to take measures to respect, protect and fulfill the right to health for all children, and the global health community can use human rights mechanisms to strengthen accountability for the SDGs. A “web of accountability” for multi-sectoral action to address interconnected determinants of child health will involve empowering (1) individuals to raise human rights claims for social determinants of health in judicial bodies; (2) civil society to work directly with policymakers to frame rights-based obligations for health and identify where States fail to meet those health obligations; and (3) the UN to conduct formal independent reviews.10
In these independent reviews, external monitoring has become necessary for human rights accountability, overcoming an ‘enforcement problem’ in human rights through State reporting and public assessment.11 States are developing follow-up and review processes to ensure that their actions in the SDG era will “respect human rights and have a particular focus on the poorest, most vulnerable and those furthest behind.”12 Holding governments accountable for equitable health outcomes could involve strategic use of health equity indicators in national monitoring frameworks, expanded human rights advocacy on determinants of health or human rights treaty body assessments.13 As national health strategies incorporate the SDGs and engage with other sectors, new indicators and monitoring strategies may be required to address social determinants of child health.14
Global development partners like UNICEF and WHO can support national accountability mechanisms, including the monitoring of progress on SDG targets. All partners can promote children’s right to health as a foundation for creating sustainable, healthy and stable societies and assist in mutually monitoring State reports (as in the Joint Monitoring Programme) to hold individual States and the global community accountable for equitably protecting the child’s right to health.
Implementing SDG targets collectively is consistent with the interrelated nature of human rights. Because human rights are indivisible and interrelated, an HRBA to child health can conceptualize the SDGs as mutually dependent and prioritize attention to equity—therefore stimulating integrated, multi-sectoral action to realize children’s right to health. There are definite opportunities for taking a greater rights-based approach for child health in the SDG era: through the language and discourse of the SDGs themselves, in setting their indicators and in building
the surrounding global architecture. Positive signs that this may occur can already be seen in the greater emphasis on human rights in the Global Strategy for Women’s, Children’s and Adolescents’ Health and the plan for an Independent Accountability Panel. These efforts need to be supported at global and national levels for the SDGs to ensure that the targets are interpreted and acted upon through a human rights lens to realize the right to health for every child by 2030.
This blog post reflects the views of its authors only, and does not necessarily represent the views or policies of their affiliated institutions.
Brief author bios
Jennifer J. K. Rasanathan is a primary care physician with a background in human rights and sexual and reproductive health
Benjamin Mason Meier is an Associate Professor of Global Health Policy at the University of North Carolina at Chapel Hill
Kumanan Rasanathan is a Senior Health Specialist at UNICEF in New York
1 United Nations General Assembly. Transforming Our World: the 2030 Agenda for Sustainable Development. Annex to A/69/L.85. http://www.un.org/ga/search/view_doc.asp?symbol=A/69/L.85&Lang=E. Accessed September 20, 2015.
2 UNICEF/WHO/World Bank/UN. Levels & Trends in Child Mortality: Report 2015. Estimates Developed by the UN Inter-Agency Group for Child Mortality Estimation; 2015. http://www.childmortality.org/files_v20/download/IGME%20Report%202015_9_3%20LR%20Web.pdf. Accessed September 13, 2015.
3 See note 2.
4 Carrera C, Azrack A, Begkoyian G, et al. The comparative cost-effectiveness of an equity-focused approach to child survival, health, and nutrition: a modelling approach. Lancet. 2012;380(9850):1341-1351. doi:10.1016/S0140-6736(12)61378-6.
5 Black RE, Victora CG, Walker SP, et al. Maternal and child undernutrition and overweight in low-income and middle-income countries. Lancet. 2013;382(9890):427-451. doi:10.1016/S0140-6736(13)60937-X.; Gakidou E, Cowling K, Lozano R, Murray CJ. Increased educational attainment and its effect on child mortality in 175 countries between 1970 and 2009: a systematic analysis. Lancet. 2010;376(9745):959-974. doi:10.1016/S0140-6736(10)61257-3.
6 See note 1
7 See note 1
8 See note 1
9 Glass RI, Guttmacher AE, Black RE. Ending preventable child death in a generation. JAMA. 2012;308(2):141-142. doi:10.1001/jama.2012.7357; Jamison DT, Summers LH, Alleyne G, et al. Global health 2035: a world converging within a generation. Lancet. 2013;382(9908):1898-1955. doi:10.1016/S0140-6736(13)62105-4; UNICEF. Committing to Child Survival: A Promise Renewed Progress Report 2015. New York, New York; 2015. http://www.apromiserenewed.org/wp-content/uploads/2015/09/APR_2015_8_Sep_15.pdf. Accessed September 14, 2015.
10 Meier BM, Cabrera OA, Ayala A, Gostin LO. Bridging international law and rights-based litigation: mapping health-related rights through the development of the Global Health and Human Rights Database. Health Hum Rights. 2012;14(1):E20-35; Yamin AE, Gloppen S. Litigating Health Rights: Can Courts Bring More Justice to Health? Cambridge, MA: Human Rights Program, Harvard Law School : Harvard University Press; 2011; Roth K. Defending Economic Social and Cultural Rights: Practical Issues Faced by an International Human Rights Organization. Hum Rights Q. 2004;26:63; Hunt P. SDG SERIES: SDGs and the Importance of Formal Independent Review: An Opportunity for Health to Lead the Way. Health Hum Rights J. http://www.hhrjournal.org/2015/09/02/sdg-series-sdgs-and-the-importance-of-formal-independent-review-an-opportunity-for-health-to-lead-the-way/. Accessed September 14, 2015.
11 O’Flaherty M, Tsai PL. Periodic Reporting: The backbone of the UN Treaty Body Review Procedures. In: Cherif Bassiouni M, Schabas WA, eds. New Challenges for the UN Human Rights Machinery. Antwerp: Intersentia; 2012:37-56; Hafner-Burton EM. Sticks and Stones: Naming and Shaming the Human Rights Enforcement Problem. Int Organ. 2008;62(04):689-716. doi:10.1017/S0020818308080247
12 see note 1
13 Brown R. SDG SERIES: Leaving No One Behind: Human Rights and Accountability are Fundamental to Addressing Disparities in Sexual and Reproductive Health. Health Hum Rights J. http://www.hhrjournal.org/2015/09/07/sdg-series-leaving-no-one-behind-human-rights-and-accountability-are-fundamental-to-addressing-disparities-in-sexual-and-reproductive-health/. Accessed September 14, 2015; MacNaughton G, Hunt P. Health impact assessment: the contribution of the right to the highest attainable standard of health. Public Health. 2009;123(4):302-305. doi:10.1016/j.puhe.2008.09.002; Mason Meier B, Getgen Kestenbaum J. The Commission on Information and Accountability for Women’s and Children’s Health: Establishing international processes for state reporting to an independent monitoring body. Health Hum Rights J. http://www.hhrjournal.org/2011/04/28/the-commission-on-information-and-accountability-for-womens-and-childrens-health-establishing-international-processes-for-state-reporting-to-an-independent-monitoring-body/. Accessed September 14, 2015.
14 Rasanathan K, Damji N, Atsbeha T, Brune Drisse M, Davis A, Dora C, et al. Ensuring multisectoral action on the determinants of reproductive, maternal, newborn, child, and adolescent health in the post-2015 era. BMJ. 2015;351:h4213.
Previous publications in HHRJ by Benjamin Mason Meier
Previous publications in HHRJ by Kumanan Rasanathan