Eng
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Protect the promise: 2022 progress report on the Every Woman Every Child Global Strategy for Women’s, Children’s and
Adolescents’ Health (2016–2030)
© World Health Organization and the United Nations Children’s Fund (UNICEF), 2022
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Contents
Foreword................................................................. vi
Message from the Global Advocate for Every
Woman Every Child......................................... vii
Acknowledgements.............................................. viii
Abbreviations.......................................................... ix
Introduction
The impact of the “three C’s”: COVID-19
pandemic, conflict and climate change................. 2
Section 1
1.1. The 2030 Agenda in the current and evolving
global context.......................................................... 5
1.2 Inequalities in progress and prospects for
children......................................................................6
Panel 1. The "freefall" of women’s and
children’s health and survival in Afghanistan.. 11
Panel 2. The growing urgency to support
displaced, refugee and migrant women and
children.............................................................. 14
1.3 Reaching women, children and adolescents
through primary health care...................................16
1.4 Women’s empowerment: an essential
ingredient to improving women’s, children’s and
adolescents’ health and well-being...................... 21
Panel 3. The case for adolescent and youth
participation......................................................26
1.5 Conflict and climate impacts on food
security are putting millions of women and
children at risk........................................................ 28
Section 3
3.1 Key points from this progress report and
lessons learned to help guide future efforts........ 45
3.2 Recommendations to accelerate progress to
benefit all women, children and adolescents...... 47
Panel 5. Addressing data gaps to achieve
Agenda 2030..................................................... 51
Panel 6. Financing for women’s, children’s and
adolescents’ health.......................................... 53
References...............................................................56
Annex
Global Strategy indicators..................................... 68
Contents v
Foreword
A more equitable world is one of the most important promises
of the Sustainable Development Goals. Sadly, this report shows
that with regard to the health and rights of women and children,
that promise is not being kept. Far from a progress report, this
document describes a reversal. Women’s and children’s health
and rights are threatened to a degree not seen in more than a
generation.
António Guterres
Secretary-General
United Nations
Foreword vii
Acknowledgements
This report was developed in support of the Every Woman Every Child Global Strategy for Women’s,
Children’s and Adolescents’ Health (2016 –2030). Contributing organizations include the United Nations
Children’s Fund (UNICEF), World Health Organization (WHO), United Nations Population Fund (UNFPA),
Partnership for Maternal, Newborn & Child Health (PMNCH) and Countdown to 2030 for Women’s,
Children’s & Adolescents’ Health.
Contributors
Lead writers: Jennifer Requejo (UNICEF), Theresa Diaz (WHO).
Additional writing team: Petra ten Hoope-Bender (UNFPA), Ties Boerma (Countdown to 2030).
Production team: Vivian Lopez (UNICEF), Ilze Kalnina (PMNCH), Jeff Hoover (consultant), Brigitte Stark-
Merklein (consultant), Natalie Bailey (Every Woman Every Child), Jennifer Requejo (UNICEF), Theresa
Diaz (WHO), Yasmine Hage (UNICEF), Baishalee Nayak (consultant).
Additional contributors: Nadia Akseer (Johns Hopkins University), Avni Amin (WHO), Valentina Baltag
(WHO), Anshu Banerjee (WHO), Jenny Cresswell (WHO), Leonardo Ferreira (Federal University of
Pelotas), Lauren Francis (UNICEF), Lucia Hug (UNICEF), Domenico Gerardo Iaia (PMNCH), Heide
Johnston (WHO), Elizabeth Katwan (WHO), Berit Kieselbach (WHO), Etienne Langoise (PMNCH),
Gerard Lopez (WHO), Lois Park (University of Southern California), Kimberly Peven (WHO), Mehr Shah
(PMNCH), David Sharrow (UNICEF), Kathleen L. Strong (WHO), Cesar Victora (Federal University of
Pelotas).
Reviewers: Agbessi Amouzou (Johns Hopkins University), Aluisio Barros (Federal University of
Pelotas), Sarah Bar-Zeev (UNFPA), Maureen Black (University of Maryland, RTI), Robert Black (Johns
Hopkins University), Liliana Carvajal (UNICEF), Bernadette Daelmans (WHO), Danielle Engel (UNFPA),
Helga Fogstad (PMNCH), Laurence Gummer-Strawn (WHO), Regina Guthold (WHO), Mark Hanson
(PMNCH co-chair, Knowledge and Evidence Working Group), Tedbabe Defefie Hailegebriel (UNICEF),
Chika Hayashi (UNICEF), Theadora S. Koller (WHO), Julia Krasevec (UNICEF), Yang Liu (UNICEF), Lori
McDougall (PMNCH), Suguru Mizunoya (UNICEF), Padraic Murphy (UNICEF), Anayda Portela (WHO),
Will Zeck (UNFPA), and the PMNCH Accountability Working Group (see members below).
PMNCH Accountability Working Group members: Sana Contractor, Nourhan Darwish, Theresa Diaz,
Lucy Fagan, Smita Gaith, Vineeta Gupta, Susannah Hurd, Dan Irvine, Mande Limbu, Jaideep Malhotra,
Harriet Nayiga, Oyeyemi Pitan, Miriam Sangiorgio, Petrus Steyn, Guknur Topcu.
Leadership and management of the group: Sophie Arseneault (vice chair, under 30 years of age),
Pauline Irungu (co-chair), Ilze Kalnina (PMNCH Secretariat), Jonathan D. Klein (vice chair), Jennifer
Requejo (co-chair).
But nearly halfway through the 2030 Agenda, the outlook in 2022
is less promising despite the unprecedented gains and lives
saved over the past decade or more. For nearly three years, the
COVID-19 pandemic has damaged the world in numerous ways,
including by destabilizing access to and availability of health
services, and recovery has been slow, intermittent and uneven. Yet
the pandemic is not solely to blame for the world falling behind
in achieving key global targets because progress had already
been too slow or had halted before its onset. For example:
• The global share of pregnant women living with HIV
who had access to antiretroviral treatment (ART), a
vital intervention that can keep them healthy while also
preventing their infants and young children from contracting
the virus, surged from 46% in 2010 to 81% in 2015, but
six years later in 2021 it was the same at 81% (3).
• Although the global maternal mortality ratio (MMR)
declined by 38% from 2000 to 2017, that translated into an
average annual rate of reduction of just 2.9% – less than
half the 6.4% annual reduction rate needed to achieve
the global Sustainable Development Goal (SDG) target
of 70 maternal deaths per 100 000 live births (4).
• Global coverage of immunization services has stalled for
many years, leaving millions of children unprotected. For
example, coverage for the third dose of diphtheria-tetanus-
pertussis (DTP) stagnated for a decade before declining from
86% to 81% during the first two years of the pandemic (5).
• After several years of slow adoption and scale-up, global
coverage of the first dose of vaccination against human
papillomavirus (HPV) also declined by five percentage
points, from 20% in 2019 to 15% in 2021, leaving millions of
adolescent girls at risk of cervical cancer later in life (6).
1
INTRODUCTION
Introduction 3
Section 1
© UNICEF/UN0309038/Kokic
The 2030 Agenda sets out an ambitious road map for human
development, recognizing that success depends on remedying
entrenched patterns of inequality and poverty and that early
life experiences influence later outcomes with potential
intergenerational effects. The SDGs extend well beyond survival,
and include targets for nutrition, child development and education.
They also encompass health determinants such as economic
and environmental goals and an emphasis on multisectoral and
partnership-based approaches to achieving progress. Threaded
throughout the SDGs is the principle of equity, including in
regard to gender equality and women’s empowerment.
With all these shifts and developments – and in this third year
of the COVID-19 pandemic and recent rising levels of food and
economic insecurity – it is important to take stock of how the
world is doing in fulfilling the promise of the SDGs and the lofty
5
SECTION 1
Policies
Services
Communities Health
Nutrition
Families
Safety/
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oo
oo
nc
o
security
at
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en
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Pr
ch
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Ad
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pt
Bi
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nc
Learning
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M
fa
on
In
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Pr
Relationships
50
Neonatal mortality rate
Significant progress
was made in reducing Child (aged 1–59
child mortality, but months) mortality rate
40 progress has slowed. In
2020, 5 million children Child (aged 5–9
died before age 5. months) mortality rate
30
10–14 years) mortality
rate
10
0
2000 2002 2004 2006 2008 2010 2012 2014 2016 2018 2020
Definitions:
Neonatal mortality rate: probability 5–9 years mortality rate: probability 15–19 years mortality rate:
of dying between birth and exact of dying between age 5 years and probability of dying between age
age 28 days (expressed per 1000 age 10 years (expressed per 1000 15 years and age 20 years
live births) children aged 5 years) (expressed per 1000 children aged
15 years)
1–59 months mortality rate: 10–14 years mortality rate:
probability of dying between age probability of dying between age
28 days and exact age 5 years 10 years and age 15 years
(expressed per 1000 children aged (expressed per 1000 children aged
28 days) 10 years)
1 in 4800
adolescents live in Africa and Asia, Africa is the only region
where the child and adolescent population is projected to
increase throughout the SDGs period and beyond (21,31,32). Europe and North
This estimated increase in Africa’s child population has serious America
implications for countries in the region already facing resource
challenges to provide every pregnant woman with essential
maternal care and every child with needed health, nutrition,
education, water and sanitation, and social protection services.
Very low (<100) Low (100–299) High (300–499) Very high (500–999) Extremely high (>1000)
75
countries
27
countries
14
countries
13
countries
2
countries
Notes: The boundaries and names shown and the designations used on this map do not imply the expression of any opinion
whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area of its
authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on this map represent approximate
border lines for which there may not yet be full agreement.
Fig. 1.4. Maternal and adolescent health in Afghanistan between 2000 and 2020
1500
Maternal mortality
ratio (modeled
estimate, per 100 000
live births)
Adolescent fertility
rate (births per 1000
1000 women ages 15–19)
0
2000 2002 2004 2006 2008 2010 2012 2014 2016 2018 2020
Other drivers of Afghanistan’s success since 2001 included improvements in girls’ and
women’s education and political participation. The number of girls in primary school
increased from a few hundred to 2.5 million from 2001 to 2018 (48,50), and lower
secondary completion rates for girls increased from 8.9% to 43.1% over 2005–2019 (51).
Female youth literacy increased from 22% to 42% from 2000 to 2021 (52), and by 2005,
about 30% of national parliament seats were held by women, a share that stayed about
the same through 2021 and is higher than the world average in 2021 of 26% (53).
Substantial commitment and financial support from the international community, which
totalled over US$ 80 billion over the past two decades (54), was essential for these successes.
However, the withdrawal of United States of America troops and the subsequent political
upheaval in August 2021 resulted in the country falling into a period of uncertainty (55). Reduced
international support and development funding, crippling international sanctions, unprepared
new authorities, mass exodus of skilled professionals and the resultant so-called brain drain,
recurrent natural disasters, and severe restrictions on girls and women have combined to create
an ongoing humanitarian crisis in the country (56).
Today, almost one year after the regime change, the plight of Afghan women and
children seems bleak, as illustrated by the following data and estimates:
• Over 24.4 million Afghans need humanitarian assistance, of whom 18.1 million
require immediate health care (57). Those needing life-saving care include 3.2
million children aged under 5 years and some 350 000 pregnant women (57).
• Maternal mortality is on the rise, and according to one estimate, the MMR might increase
by 50% (from 638 to 963 deaths per 100 000 live births) by 2025 in the absence of serious
and comprehensive intervention (58). That increase would translate into a woman
dying from childbirth or pregnancy complications every two hours in Afghanistan.
• Many pregnant women remain vulnerable because of relatively low access to
antenatal and postnatal care (59) and skilled birth attendance. It is estimated that
20% of deliveries and newborns require lifesaving emergency interventions,
yet these are not readily accessible to most women due to restricted
mobility, limited capacity of providers and weak referral systems (60).
• Unmet sexual and reproductive health needs have spiralled for women and
girls since August 2021 (59). The United Nations Population Fund (UNFPA)
estimates that unmet need for family planning could increase to almost 40%
and about 4.8 million unintended pregnancies could occur by 2025 (58).
A recent Integrated Food Security Phase Classification analysis estimated that between
March and May 2022, about 47% of the population (19.7 million people) was in crisis
or experiencing emergency food insecurity (61). The health and nutrition of women
and children are undoubtedly further compromised by these pervasive food shortages.
Additionally, Afghanistan continues to grapple with multiple disease outbreaks,
including COVID-19, measles, acute watery diarrhoea, leishmaniasis, malaria and
scabies, which further stress an already strained and broken health system (60).
In August 2021, secondary education (above grade 6) for girls in Afghanistan was
discontinued, a step that made Afghanistan the only country in the world to prohibit girls
from completing their education (64). These restrictions have effectively deprived girls and
women of their basic rights and curtailed their life opportunities. Although female teachers,
nurses, doctors and civil servants have been allowed to continue working under restricted
protocols, cutting education access for girls and young women severs the pipeline of
educated women to fill these roles in the future (65). Moreover, gender segregation and
shortages of female teachers and health service providers have reduced access to and
quality of maternal and child health services and available education for girls (66).
The impact of restrictions on girls and women extends to other facets of life, such as social
engagement and employment (67). Many women have lost jobs since August 2021 due to
the restrictions on mobility and conditions on public participation. Job losses have been
observed across most sectors, with women in particular professions (e.g., media and civil
society) reporting additional challenges due to the often-public nature of their work. The
combination of restrictions – including women’s right to work, gender segregation in the
workplace, clothing regulations, mahram requirements (male accompaniment during travels),
and safety and security concerns regarding travelling to and from work – have resulted in
most women choosing not to work or to work from home (68). This climate of fear, uncertainty
and mobility restrictions inevitably impacts women’s mental health and their ability to work,
pursue education, seek vital health services and participate in public and political life (68).
Given the difficult and complex obstacles that women, children and adolescents
face in Afghanistan, improving their ability to survive and thrive requires
interventions in a range of areas and by key actors nationally and internationally.
Recommended actions and focus areas include the following:
• The international sanctions on Afghanistan should be eased for the country’s economy
to revert to a sense of normalcy. Restrictions on trade and limited cash liquidity are
contributing to catastrophic levels of household poverty, which is the root cause of
many health and nutrition challenges affecting families in the country. The Government
of the United States of America and allies should prioritize finding a solution
• Immediate reinstatement of health and development funding from Afghanistan’s
long-term donors is essential. A full year after the 2021 regime change, the country
continues to be in crises mode and the newer government has not managed to secure
development funding or establish strong public institutions. Without the international
community’s support, Afghanistan’s systems and development achievements could
easily crumble within a matter of years. The World Bank and partners have recently
committed US$ 793 million for food, health and livelihoods through the Afghanistan
Reconstruction Trust Fund (ARTF), a welcome step in this direction (69).
• Afghanistan’s basic package of health services and essential package of hospital services
must continue to be the minimum official standard, and should be revised in light of
the changing epidemiology and population migration. The World Bank, European Union
and the United States Agency for International Development (USAID) have played
prominent roles in funding and scaling these packages country-wide in Afghanistan
since 2001. These actors should now explore innovative financing and contracting
mechanisms with nongovernmental organizations to protect health services at all costs.
• The humanitarian needs for food, clean water and sanitation, health and
education are monumental. Humanitarian players on the ground such as WFP
and UNICEF require immediate and generous funding to continue protecting
the lives and welfare of women, children and families in Afghanistan.
• The health and well-being of Afghan girls and women lies in the hands of Afghanistan’s
new government, and its officials must think responsibly and holistically about how to
protect and support this critical mass of Afghan society. In particular, the government
should recognize that educating girls and permitting women to have an equal standing
in society advances economic growth, improves public health, reduces conflict and
enhances environmental sustainability. The status of girls and women in Afghan
societies today is dismal. Despite challenges, the international community should
continue advocating for and promoting gender-sensitive programming in all efforts.
In recent years, millions of people have been internally displaced or have fled across borders
to escape armed conflict in the Democratic Republic of the Congo, the Syrian Arab Republic,
Ukraine and Yemen, among several other countries, with millions of others being displaced by
droughts, floods, wildfires, land degradation and severe storms that are increasing in intensity
due to climate change. These crises can compound and exacerbate problems such as economic
stress and food insecurity that in turn prompt more migration, creating a vicious circle. In
places such as Afghanistan, all three of these existential challenges (conflict, climate change
and severe economic stress) have converged at once, as discussed in Panel 1 of this report.
Recent data show that the overall situation is getting worse. At the end of 2021, an estimated
89.3 million people worldwide had been forcibly displaced as a result of conflict, fear of
persecution, violence and human rights violations (70). That was more than double the
number a decade ago in 2012 (42.7 million) and the most since the Second World War (70,71).
With some 6 million or more Ukrainians having fled their homes since the beginning of
2022 and major displacements in places such as Burkina Faso and Myanmar, the total global
forced displacement was assumed to exceed 100 million by the middle of the year (72).
Children and women are often disproportionately affected by forced migration. One
reason is pure numbers: Children make up over half of the world’s refugees (73) and
accounted for about 41% of the 89.3 million forcibly displaced people at the end of 2021
(70), both of which are substantially higher percentages than their 30% share of the
world’s population. The number of displaced children almost certainly has increased in
Children and adolescents experiencing displacement face numerous risks to their health and
well-being, especially if their families are destitute and living in overcrowded conditions.
Threats range from malnutrition to diarrhoeal illnesses due to poor sanitation to sexual
and other forms of violence to post-traumatic stress symptoms (71). Preventing and
treating these and other conditions can be difficult due to lack of access to health services,
including for mental health. Children’s and adolescents’ education is often disrupted or
ended altogether by displacement and long periods living in refugee settlements, with
girls and young women particularly likely to miss out on or drop out of school (71).
Women’s ability to work, travel or seek support for themselves and their families is often
constrained by restrictive policies and fears of violence or detainment by authorities.
The COVID-19 pandemic complicated the plight of migrants and refugees in several ways.
Country measures to limit internal mobility and to tighten borders to fight the virus’s spread
left many migrants and refugees stranded, often in precarious situations. Cramped conditions
in many refugee settlement camps also increased the risk of rampant spread of the virus that
causes COVID-19. (See Section 2 for a more detailed discussion of COVID-19’s impacts.)
Improving the life conditions and prospects of migrant and refugee women and children
is important for achieving progress towards the 2030 Agenda. One approach relevant for
all stakeholders is to strengthen commitment to the twin global compacts on migration
and refugees adopted by the United Nations General Assembly in 2018 (73,76). At the
core of the Global Compact on Safe, Orderly and Regular Migration are 23 objectives for
better managing migration at local, national, regional and global levels. Its child-sensitive
overlay includes this pledge: “We further commit to uphold the best interests of the child
at all times, as a primary consideration in situations where children are concerned, and to
apply a gender-responsive approach in addressing vulnerabilities, including in responses
to mixed movements.” In practice, among other things, this means that signatories commit
to provide migrant children with access to education, to include them in child protection
schemes, to enable family reunification, and to prevent child labour and exploitation.
The Global Compact on Refugees commits signatories to “adopt and implement policies
and programmes to empower women and girls in refugee and host communities,
and to promote full enjoyment of their human rights, as well as equality of access to
services and opportunities.” This commitment includes a vow to “contribute resources
and expertise towards policies and programmes that take into account the specific
vulnerabilities and protection needs of girls and boys, children with disabilities, adolescents,
unaccompanied and separated children, survivors of sexual and gender-based violence,
sexual exploitation and abuse, and harmful practices, and other children at risk.”
Another action beyond strengthening commitment to these compacts is to invest in data systems
on migrants and refugees to inform analysis and decision-making. More information is needed
on how, why, and where children migrate and who they are. Gathering data on migrants and
refugees that can be disaggregated by age and sex would also help with planning services for
women and children. Providers and funders of services for internally displaced persons, refugees
and other migrants also should build on and expand digital-based innovations, including those
introduced during COVID-19, to reach and support women and children on the move (77).
© UNICEF/UN0560343/Urdaneta
100
75
Coverage estimate (%)
50
25
0
Demand for family planning
satisfied with modern methods
Exclusive breastfeeding
(<6 months)
Continued breastfeeding
(year 1)
DTP3 immunization
MCV1 immunization
Rotavirus immunization
Vitamin A supplementation
(two doses)
Table 1.1. Median national coverage of interventions across the continuum of care for all
low- and middle-income countries*
Number of
Indicator Median Min Max countries
with data
Pre-pregnancy
Demand for family planning
53 2 90 61
satisfied with modern methods
Pregnancy
Antenatal care (four or more visits) 78 24 100 76
Treatment of pregnant women living with HIV 76 4 100 90
Neonatal tetanus protection 90 60 99 99
Birth
Skilled attendant at birth 96 32 100 97
Postnatal
Postnatal visit for mothers 84 10 100 66
Postnatal visit for babies 83 10 100 62
Early initiation of breastfeeding 52 8 92 72
Infancy
Exclusive breastfeeding (<6 months) 42 9 81 70
Continued breastfeeding (year 1) 77 25 98 61
DTP3 immunization 85 31 99 134
MCV1 immunization 82 18 99 134
Rotavirus immunization 78 9 99 86
Childhood
Vitamin A supplementation (two doses) 32 0 99 64
Pneumonia: Care-seeking for
69 18 98 55
symptoms of pneumonia
Diarrhoea: Oral rehydration
40 14 85 59
salts (ORS) treatment
Environment
Population using at least basic
92 37 100 133
drinking-water services
Population using at least basic
79 9 100 133
sanitation services
*The total number of countries included in the analysis is all 136 low-and middle-income countries based on the World Bank
classification for fiscal year 2023, based on 2021 gross national income (GNI) per capita, updated in July 2022. For each indicator,
only countries with available data from 2017 and later are included in the analysis. Black dots represent national estimates and bar
represents the median among all countries with available data.
Fig. 1.6. Per cent of under-5 deaths by age group: 54 countries off track for SDG 3.2.1
© UNICEF/UN0694102/Moskalenko
Coverage of reproductive and maternal health services shows
similar patterns of inequities across countries as well as
within countries, with poor and other disadvantaged groups
of women much less likely to receive these services than their
wealthier counterparts (100-103). (The report’s annex contains
detailed information about access to such services grouped
by country wealth quintile and other categories.) Nearly all
(97%) unsafe abortions, for example, occur in developing
countries3, with the highest proportions of least safe abortions
and highest case fatality rates occurring in Africa, where
access to services are limited (104). Unsafe abortion is a major
cause of maternal mortality (105).
SWPER tercile
Malawi
Indonesia
Zambia
South Africa
Zimbabwe
Sierra Leone
Rwanda
India
Philippines
Bangladesh
Cameroon
Myanmar
Gambia
Uganda
Liberia
Nepal
Timor-Leste
Burundi
Pakistan
Albania
Senegal
United Republic of Tanzania
Papua New Guinea
Haiti
Cameroon
Mali
Benin
Niger
Mauritania
Afghanistan
Nigeria
Angola
Guinea
0 30 40 50 60 70 80 90
with health outcomes, in 32 countries with available data6. The CCI is a weighted average
of eight essential interventions for women’s and children’s health (133)7. As shown in
the figure, coverage levels of the CCI are highest among women scoring in the top
tercile of the social independence component of the SWPER in all but one country.
Achieving the SDGs cannot be done without improving the health and well-being of
adolescents and young people (the adolescent period is defined by WHO and UNICEF as ages
10–19 years, with young people aged 20–24 years). The numbers alone make this evident:
according to the latest UN estimates, 41% of the global population is younger than 24 and
around 16% is aged 15–24 years (134). Most of the world’s more than 1.2 billion young people
aged 15–24 years live in LMICs (31,134). It is these countries where health, education and
social services are lagging the furthest behind and where adolescents and young people
face the greatest challenges to their ability to survive and thrive. Increases in rates of child
marriage, adolescent depression and anxiety, and violence against women and girls in
the past two years are just a few of the trends that have heightened their vulnerability.
UNICEF defines adolescent participation as “about being informed, engaged and having
a voice and influence in decisions and matters that affect one’s life – in private and public
spheres, in the home, in alternative care settings, at school, in the workplace, in the
community, in social media, in peace processes and in broader governance processes”
(140). Participation is also a central theme of My Body, My Life, My World, the UNFPA global
strategy for adolescents and youth launched in November 2019. The My World pillar is a
call to “promote the leadership of adolescents and youth and their fundamental right to
participate in sustainable development, humanitarian action and in sustaining peace” (141).
This approach is based on the recognition that policies and services are more likely to meet
the needs of adolescents when they have a say in their development and implementation.
WHO and UNICEF have published guidance materials on adolescent participation and
engagement in health and other sectors that can be adapted for different settings (140,142).
UNFPA’s adolescent and youth strategy includes the following call to action: “Services fully
geared to realizing the rights and choices of adolescents and youth must be integrated
in comprehensive sexual and reproductive health and rights interventions, policies and
programmes. All health care providers should have accurate and adequate skills to serve
adolescents and youth, and all health facilities should offer necessary commodities, services
and information” (141). As part of its efforts to put this strategic priority into practice, UNFPA
partnered with UNICEF to introduce in 2021 the Gender-Transformative Accelerator Tool of
the Global Programme to End Child Marriage. One of the tool’s top objectives is to build and
support adolescent girls’ skills, agency and empowerment by promoting their increased
engagement in developing and leading efforts to reduce early marriage. In less than a year,
the tool had been rolled out in several countries including Ethiopia, India and Niger.
Increased opportunities for youth participation in community activities and in civic life are
also needed to improve inclusivity, innovation, and to help build the next generation of
leaders. United Nations agencies, the Partnership for Maternal, Newborn & Child Health
(PMNCH), and other organizations have supported several initiatives in this area, including
leadership skills-building opportunities for adolescents and young people (141,143,144).
The fact that many agencies and organizations are promoting youth participation
underscores its importance as a vital strategy for improving their lives and tackling the
existential threats they face. Expansion of efforts to increase adolescent participation
in research, in programme design and implementation across sectors, and in civic
engagement could result in immediate improvements in adolescent health and well-
being plus longer-term benefits of building the next crop of effective leaders.
Current food crises and the rise in global hunger are attributed to
an often mutually reinforcing set of drivers, including pandemic-
induced economic contractions and supply chain disruptions,
extreme climate events such as the drought conditions affecting
the Horn of Africa, and conflict situations. When underlying
drivers such as these are left unresolved, food crises can become
protracted with cumulative negative impacts on women and
children. According to WFP’s latest global report on food crises,
conflict and insecurity was the primary driver in 7 of the top
10 food crisis countries (Afghanistan, the Democratic Republic
of the Congo, Ethiopia, Haiti, Nigeria, Pakistan, South Sudan,
Sudan, the Syrian Arab Republic and Yemen) (148). Families
displaced from their homes due to conflict are among the most
vulnerable to acute food insecurity and malnutrition, as noted
in Panel 2. In 2021, the six countries with the highest numbers
of internally displaced persons – Afghanistan, the Democratic
Republic of the Congo, Ethiopia, Sudan, the Syrian Arab Republic
and Yemen – were among the top 10 food crisis countries (148).
Since early in 2022, the war in Ukraine has exposed some perils
of the interconnectedness of global food chains and the fragility
of food systems in many LMICs. Countries from Egypt to Sri
Lanka to Kenya are coming under strain from weather extremes,
All forms of malnutrition – undernutrition, overweight and obesity, In 2021, the six
and micronutrient deficiencies – negatively affect individuals,
countries with the
communities and societies with potential intergenerational
effects. Poor nutrition during early life impedes both physical highest numbers
and cognitive development, reduces school performance of internally
and adult productivity, and increases the risk of overweight
and diet-related chronic diseases in adulthood (152).
displaced persons
– Afghanistan,
Achieving healthy growth and development in children starts with the Democratic
ensuring women have access to adequate nutritious foods (153).
Women who have experienced chronic malnutrition are at higher Republic of the
risk of obstructed labour due to cephalopelvic disproportion, Congo, Ethiopia,
and those with poor diets before and during pregnancy have an
elevated risk of anaemia, pre-eclampsia, haemorrhage and death.
Sudan, the Syrian
Latest global estimates indicate that around 15% of all women are Arab Republic and
obese (150,154) and women with obesity are at increased risk of Yemen – were
almost all pregnancy complications. Poor maternal nutrition can
also result in stillbirth, low birth weight, neural tube defects and among the top
developmental delays in babies. Before the pandemic hit in 2019, 10 food crisis
an estimated 9% of women aged 20 years and older worldwide
countries
were underweight (body mass index below 18.5) (155) and around
571 million women aged 15-49 years (29.9%) were anaemic (156).
These numbers have likely increased in the past two years.
Fig. 1.8 Percentage of children aged under 5 years affected by stunting, wasting and overweight,
global, 2000 and 2020*
40 250
35
200
30
Number (millions)
25
150
Percentage
20
15 100
10
50
5
0 0
2000 2020 2020 2000 2020 2000 2020 2020 2000 2020
*Household survey data on child height and weight were not collected in 2020 due to physical distancing policies, with the exception
of four surveys. These estimates are therefore based almost entirely on data collected before 2020 and do not take into account the
impact of the COVID-19 pandemic. However, one of the covariates used in the country stunting and overweight models takes the
impact of COVID-19 partially into account.
©UNICEF/UN0436094/Prinsloo
COVID-19 pandemic
© UNICEF/UN0517418/Panjwani
More than halfway through the third year of the pandemic, much
has been learned about transmission and the direct health effects
of SARS-Cov-2 infection in pregnant women and their newborns,
and in children and adolescents. A growing body of evidence also
exists on the economic and indirect impacts of the pandemic,
including negative effects of country response measures on
women’s and children’s health and well-being. Among these
adverse consequences are disruptions to health and social
services, educational loss, increased poverty, worsening mental
health, and reduced safety and security from all forms of violence.
33
SECTION 2
© UNICEF/UN0666073/Prasad Ngakhusi
COVID-19 pandemic threats to the health and well-being of women, children and adolescents 35
SECTION 2
Fig. 2.1. Restoring access to key services for women and children in the
COVID-19 era: slow but steady progress since early 2021
Comparison of disruptions for SRMNCAH services in countries that responded to all three
rounds of the WHO global pulse survey on continuity of essential health services during
the COVID-19 pandemic: Q3 2020 (round 1), Q1 2021 (round 2) and Q4 2021 (round 3)
2020
Q3 62 5 67
(n=60)
Family 2021
planning and Q1 42 5 47
(n=77)
contraception
2021
Q4 (n=64) 34 2 36
2020
Q3 (n=61) 61 2 62
Antenatal 2021
Q1 39 3 42
care (n=79)
2021
Q4 (n=62) 35 2 37
2020
Q3 (n=61) 34 3 38
Facility-based 2021
births Q1 27 1 28
(n=74)
2021
Q4 27 2 29
(n=63)
2021
Postnatal Q1 32 1 34
care for (n=74)
women and
newborns 2021
Q4 30 2 31
(n=64)
2020
Q3 52 2 53
(n=62)
0 10 20 30 40 50 60 70 80 90 100
Percentage of countries
COVID-19 pandemic threats to the health and well-being of women, children and adolescents 37
SECTION 2
Fig. 2.3 Overall health and well-being of children and adolescents two years
into the pandemic: uneven progress in ending service disruptions
Proportion (%) of countries reporting severe disruptions in at least one service type,
by sector and round of UNICEF COVID-19 socioeconomic impact survey
65% Q3 2020
Nutrition Q1 2021
36%
Q3 2021
43%
59%
Child
protection 51%
42%
54%
Health 36%
40%
23%
WASH 17%
21%
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
*Bangladesh, the Plurinational State of Bolivia, Cameroon, the Democratic Republic of the Congo, Ethiopia, India, Myanmar,
Nepal, Nigeria, Pakistan, Romania, South Africa, Sudan, Tajikistan, Timor-Leste, Uganda, Yemen.
**Three additional countries participating in this initiative (Brazil, Cambodia and Kazakhstan) are not represented in this table.
COVID-19 pandemic threats to the health and well-being of women, children and adolescents 39
SECTION 2
COVID-19 pandemic threats to the health and well-being of women, children and adolescents 41
SECTION 2
Fig. 2.4. Proportion of children who can read simple text and duration of school closures,
as of 28 February 2022
Low income
76–100%
Lower-middle income
Proportion of children who can read a simple text at age 10
Upper-middle income
High income
56–75%
36–55%
Belize Panama
Jamaica Kenya Guatemala Honduras
16–35%
Mauritania El Salvador
Comoros Plurinational State of Bolivia
Rwanda
Pakistan
Guinea South Sudan Côte d’Ivoire Uganda
Gambia Mozambique
Ethiopia
0–15%
Chad
Afghanistan Cambodia Myanmar Philippines
Democratic Republic of the Congo
0 10 20 30 40 50 60 70 80
COVID-19 pandemic threats to the health and well-being of women, children and adolescents 43
Section 3
45
The swift formation of the Access to COVID-19 Tools Accelerator
It is possible to (ACT-A), a partnership launched by WHO and partners in April 2020,
overcome many of was a rapid and innovative response to the COVID-19 crisis (199).
ACT-A brought together a consortium of stakeholders including
these challenges governments, civil society, private sector actors and global
if all stakeholders health organizations to develop and equitably deliver COVID-19
involved in tests, treatments and vaccines. It is an example of what can be
done when the global community works jointly to combat major
delivering the health threats. New efforts to improve the global architecture
2030 Agenda for addressing potential future pandemics and outbreaks such
as the proposed development of a legally binding pandemic
recognize the instrument to protect all families and communities (200,201),
urgency and the establishment of the WHO hub for pandemic and epidemic
play their part intelligence (202), and the World Bank’s Financial Intermediary
Fund for Pandemic Prevention, Preparedness and Response (14)
in accelerating reflect the global community’s commitment to continue working
progress. together on future disease outbreaks. Advocacy will be needed to
ensure that women, children and adolescents are not forgotten
in these and other evolving development-related initiatives, and
that country priorities and perspectives are placed at the centre.
The way forward: making the progress needed over the remaining eight years of the 2030 Agenda 47
• Strengthening health information systems to enable countries
to regularly collect, analyse and use high-quality data. Many
countries experience substantial data gaps, thereby limiting
their ability to use evidence to plan, implement and monitor
health policies and programmes. (See Panel 5 on such gaps
in relation to the 16 core Global Strategy Indicators.)
The way forward: making the progress needed over the remaining eight years of the 2030 Agenda 49
Secure increased financial investments by governments and
their partners in women’s, children’s and adolescents’ health
The way forward: making the progress needed over the remaining eight years of the 2030 Agenda 51
Indicators based on estimates Number of WHO Member States
for all or some countries with data or estimates (year)*
More than ever, routine health data systems are seen as extremely important to ensure
continued and real-time monitoring during emergencies such as the COVID-19 pandemic.
Due to the difficulties of conducting in-person surveys during the pandemic, WHO and
partners developed guidance on the analysis and use of routine data to monitor the effects
of COVID-19 on essential health services, with a section dedicated to reproductive, maternal,
newborn, child and adolescent health (RMNCAH) (214). Several countries used these routine
data to assess the indirect impact of the COVID-19 pandemic on health services (173-176).
Given what was learned during the pandemic, the analysis and use of health facility data
guidance for RMNCAH programme managers document (215) is being updated. It will be
critical in the future to invest more in country routine health information systems (216).
In addition to intervention coverage, it is important to measure and monitor the quality of care,
which is essential for health services to result in expected improvements in health outcomes.
However, measurement of quality of care remains fragmented and non-standardized (217).
Recently there have been efforts to improve the standardization of measures to assess quality
of care for women and children (218,219). However, just as with routine health information
systems, more investments are needed to improve this area of measurement and monitoring.
Despite the launch in 2015 of the Global Financing Facility for Women, Children and Adolescents
(GFF), financing trends for women’s, children’s and adolescents’ health prior to the COVID-19
pandemic indicated an urgent need for substantial investment to bridge worsening equity gaps
that threaten the achievement of the Global Strategy goals. While investments in many health
areas saw positive annual increases in the period 2015–2019, in many cases these increases
were smaller than those seen during the Millennium Development Goals era (2000–2015) (220).
Evidence from 2019 suggested that the previous positive trend in development assistance
for health, which had already begun to weaken, was at risk of slowing down even further
(221). Since then, COVID-19 and conflict situations such as the Ukraine crisis have negatively
impacted national economies. Both official development assistance (ODA) from donor countries
and domestic funding have been directed to response and recovery efforts, leaving less
funding available for other priorities. The need to address the climate crisis may further limit
prospects for increasing funds allocated to women’s, children’s and adolescents’ health.
Preliminary evidence from the Organisation for Economic Co-operation and Development
(OECD) suggests there was a 4.4% increase in ODA from 2020 to 2021 (222). However, this
figure is largely inflated by donations for COVID-19 vaccines. If COVID-19 vaccine purchases
are excluded, the ODA increase falls to a meagre 0.6%. ODA to low-income countries (LICs) in
2021 only grew by 1%, and by 2.5% to the least-developed countries. Cuts and reallocation of
ODA enacted by some OECD countries in 2022 (223) will have a significant detrimental impact
on the most vulnerable women, children and adolescents with potential long-term effects.
Shortfalls in ODA come against a backdrop of a reduced fiscal space that prevents
several countries, especially LICs, from securing the necessary domestic investments
to improve women’s, children’s and adolescents’ health. According to the latest macro-
fiscal projections from the International Monetary Fund, 126 countries will increase their
per capita general government expenditure (GGE) above pre-COVID levels in the next
five years (224,225). Yet in 52 countries (non-GGE-growth countries), per capita GGE is
The way forward: making the progress needed over the remaining eight years of the 2030 Agenda 53
projected to remain below pre-pandemic levels. These countries will face harsh choices
and may opt to fund other priorities at the expense of essential health services.
Two years into the pandemic, the Independent Panel on Pandemic Preparedness and
Response notes that, despite repeated calls for targeted action, there is still a lack of
domestic investment in strengthened national public health institutions, health systems
and social protection systems on the scale needed to build resilience to cope with future
crises (226). For most LICs to get on track in meeting Global Strategy targets, unprecedented
increases in health spending – reaching historical highs comparable to the extraordinary
spending commitments of high-income countries – will be required. This financing crisis
for global health needs to be widely recognised and addressed as a highest priority.
The World Bank Group, International Monetary Fund, WHO and World Trade Organization
Multilateral Leaders Task Force has called for urgent international support for countries facing
weak government spending growth in the years ahead (225). In addition to increased investment,
it is more important than ever to improve the efficiency and impact of domestic health financing
and development assistance for health. Greater political will and leadership is required to
align and direct resources in support of national goals for women, children’s and adolescents’
health, and to bolster transparent financial management and accountability mechanisms.
More evidence is required to understand how resources can be most effectively distributed and
expended at subnational levels to improve health outcomes for the most vulnerable women,
children and adolescents. Monitoring financial trends will help to build a stronger evidence base
to support financing for equity in relation to their health and well-being wherever they live.
Greater investment in women’s, children’s and adolescents’ health will have positive effects that
extend far beyond national borders. Such investment is one of the most powerful levers for a
global pandemic recovery and will build a healthier, more productive and resilient future for all.
© UNICEF/UN0688741/Dejongh
The way forward: making the progress needed over the remaining eight years of the 2030 Agenda 55
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Photo captions
Cover photo: Zenaba Oumar, 35, is cuddling her 7 months Ukraine and plans to continue living in Poland
old baby Hadja outside the health center at the Amma until it is safe to go back to their homeland.
internally displaced persons camp near Liwa, Chad. © UNICEF/UN0694102/Moskalenko
© UNICEF/UN0594629/Dejongh
Page 31: A child plays in the floodwaters in Gatumba,
Introduction: Young girl from Santa Rita, Bolivia. near Bujumbura, Burundi. Burundi, one of the poorest
© United Nations Photo/Evan Schneider countries in the world, is extremely vulnerable to natural
disasters brought on by the climate emergency.
Page 3: Mudassar, 11 months old, tastes ready-to-use © UNICEF/UN0436094/Prinsloo
therapeutic food to treat severe acute malnutrition at
the nutrition camp set up by UNICEF for flood-affected Page 32: A mother provides kangaroo care to her
children in Sukkur, Pakistan. Mudassar and his family were newborn infant in the special newborn care unit at
displaced when torrential monsoon rains and subsequent Dantewada district hospital Chhattisgarh, India.
floods washed away their village in another district. © UNICEF/UN0517418/Panjwani
© UNICEF/UN0706898/Butt
Page 34: Birendra, 10, a student at the Mahendra
Page 4: Semah, 8, poses for a portrait outside her school Secondary School in Dadeldhura district,
in Surkhrod district, Nangarhar province, Afghanistan, Nepal, receives the COVID-19 vaccine.
in 2019. She and her family came from Kunar province © UNICEF/UN0666073/Prasad Ngakhusi
to Surkhrod district so that she could attend school.
© UNICEF/UN0309038/Kokic Page 43: A mother and child in Puerto Cabezas, Nicaragua,
standing in an area devastated by Hurricane Eta.
Page16: Sanaicar, 5, and her friend Neldaisha, 4, draw © UNICEF/UN0360925/Gómez/AFP-Services
pictures at “La casita”, a shelter for unaccompanied
children in Metetí, Darién province, Panama, Page 44: A father and child at a health center in
where children are cared for and protected until Libreville, Gabon, that provides immunization
reunification with their families. The two girls are services and medical check-ups for children.
children of Haitian migrants and arrived in Panama © UNICEF/UN0671861/Alida
unaccompanied, but both were reunited with their
families the day after his picture was taken. Page 50: Muih, 7, and his parents are attending a
© UNICEF/UN0560343/Urdaneta UNICEF-supported parenting club in Gia Lai, Viet Nam.
Parenting clubs are part of a child care support system
Page 19: Waleed Al-Ahdal, who lives with his children in for mothers as well as fathers, whose role in childhood
Al Jufaina internally displaced persons camp in Marib development is highlighted during club meetings.
Governorate, Yemen, prepares the Iftar, the evening © UNICEF/UNI310365/Sinis VII Photo
meal during Ramadan, for the children and himself.
© UNICEF/UN0624745/Al-hamdani Page 55: Fatoumata Zara Alhader, 15, lives in Tahoua,
Niger. She was only 12 years old when her father wanted
Page 22: Veronika, 10, and her mother Svetlana to marry her off to a cousin, but her mother intervened.
hug each other outside their temporary apartment Fatoumata now lives with her mother and grandmother.
in Krakow, Poland. The family fled the war in © UNICEF/UN0688741/Dejongh
References 67
ANNEX:
Global Strategy indicators
The annex presents the Global Strategy indicators, organized by
the strategy’s three components of survive, thrive and transform.
Indicators displayed are those with available data on trends and
able to be disaggregated by country income group (high, upper-
middle, lower-middle and low).
Survive
Income-group trends in mortality: Maternal mortality, stillbirths, neonatal mortality,
under-5 mortality and adolescent mortality
Maternal mortality Stillbirths
900 30
Low
600
20
Low Lower-middle
300
Lower-middle 10
Upper-middle
Upper-middle
0 High
High
2010 2015 2017 2010 2015 2019
Neonatal and under-5 mortality Adolescent mortality
Females Males
90 250
(first 28 days)
mortality rate
Low Low
Neonatal
200
10–14 years
Low
Deaths per 1000 live births
60 Lower- Lower-
Lower-middle 150
middle middle
30 100 Upper- Upper-
Upper-middle
50 middle middle
0 High
High High
250
90
mortality rate
Low Low
200
15–19 years
Lower-
Under-5
Low Lower-
60 150 middle middle
Lower-middle 100 Upper- Upper-
30 Upper-middle middle middle
50
High High High
0
2010 2015 2020 2010 2015 2019 2010 2015 2019
50
100
50 25
0 0
2010 2019 2010 2019 2010 2019 2010 2019 2010 2020 2010 2020 2010 2020 2010 2020
Coverage of essential RMNCH health services Access to sexual and reproductive health care,
information, and education
High Upper-middle Lower-middle Low
services based on tracer interventions
100
Average coverage of essential
75
75
regulations
50 50
25 25
0 0
2010 2019 2010 2019 2010 2019 2010 2019 2019 2019 2019 2019
Out-of-pocket health expenses as percentage of total health expenditure Domestic general government health expenditure
High Upper-middle Lower-middle Low High Upper-middle Lower-middle Low
100
6000
Out-of-pocket payment as % of total health expenditure
75
50
2000
25
0 0
2010 2019 2010 2019 2010 2019 2010 2019 2010 2019 2010 2019 2010 2019 2010 2019
Clean fuels
High Upper-middle Lower-middle Low
100
% of population with primary reliance on clean fuels and technologies for cooking
75
50
25
0
2010 2019 2010 2019 2010 2019 2010 2019
Transform
Income-group trends in birth registration, schooling and sanitation
2010– 2016– 2010– 2016– 2010– 2016– 2010– 2016– 2010– 2016– 2010– 2016– 2010– 2016–
2015 2020 2015 2020 2015 2020 2015 2020 2015 2020 2015 2020 2015 2020
75 100
75
%
%
50
50
25
25
0 0
Rural
Urban
Rural
Urban
Rural
Urban
Rural
Urban
Rural
Urban
Rural
Urban
Rural
Urban
Rural
Urban
Rural
Urban
Rural
Urban
Rural
Urban
Rural
Urban
Rural
Urban
Rural
Urban
Schooling
Grade Grade Primary: Primary: Secondary: Secondary:
2-3: 2-3: Handwashing Sanitation
Maths Reading Maths Reading
Maths Reading
2010– 2016– 2010– 2016– 2010– 2016– 2010– 2016– 2010– 2016– 2010– 2016–
2015 2019 2015 2019 2015 2019 2015 2019 2015 2019 2015 2019
75
High
25
0
75
Upper-
25
%
middle
0
75
Lower-
25 middle
0
75
Low
25
0
Male Female
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74 2022 PROGRESS REPORT ON THE EWEC GLOBAL STRATEGY