The Lancet Commissions

A future for the world’s children? A WHO-UNICEF-Lancet
Commission
Helen Clark*, Awa Marie Coll-Seck*, Anshu Banerjee, Stefan Peterson, Sarah L Dalglish, Shanthi Ameratunga, Dina Balabanova,
Maharaj Kishan Bhan†, Zulfiqar A Bhutta, John Borrazzo, Mariam Claeson, Tanya Doherty, Fadi El-Jardali, Asha S George, Angela Gichaga,
Lu Gram, David B Hipgrave, Aku Kwamie, Qingyue Meng, Raúl Mercer, Sunita Narain, Jesca Nsungwa-Sabiiti, Adesola O Olumide, David Osrin,
Timothy Powell-Jackson, Kumanan Rasanathan, Imran Rasul, Papaarangi Reid, Jennifer Requejo, Sarah S Rohde, Nigel Rollins, Magali Romedenne,
Harshpal Singh Sachdev, Rana Saleh, Yusra R Shawar, Jeremy Shiffman, Jonathon Simon, Peter D Sly, Karin Stenberg, Mark Tomlinson,
Rajani R Ved, Anthony Costello

Executive summary
Despite dramatic improvements in survival, nutrition, andeducation over recent decades, today’s children face anuncertain future. Climate change, ecological degradation,
migrating populations, conflict, pervasive inequalities,
and predatory commercial practices threaten the healthand future of children in every country. In 2015, theworld’s countries agreed on the Sustainable Development
Goals (SDGs), yet nearly 5 years later, few countries haverecorded much progress towards achieving them. This
Commission presents the case for placing children, aged
0–18 years, at the centre of the SDGs: at the heart of theconcept of sustainability and our shared human endeavour.
Governments must harness coalitions across sectors to
overcome ecological and commercial pressures to ensurechildren receive their rights and entitlements now and a
liveable planet in the years to come.

Invest in children’s health for lifelong, intergenerational,
and economic benefits
The evidence is clear: early investments in children’s
health, education, and development have benefits thatcompound throughout the child’s lifetime, for their futurechildren, and society as a whole. Successful societies
invest in their children and protect their rights, as isevident from countries that have done well on health andeconomic measures over the past few decades. Yet many
politicians still do not prioritise investing in children, nor
see it as the foundation for broader societal improvements.
Even in rich countries, many children go hungry or live in
conditions of absolute poverty, especially those belong­
ing to marginalised social groups—including indigenous
populations and ethnic minorities. Too often, the potentialof children with developmental disabilities is neglected,
restricting their contributions to society. Additionally,
many millions of children grow up scarred by war or
insecurity, excluded from receiving the most basic health,educational, and developmental services.
Decision makers need a long-term vision. Just as good
health and nutrition in the prenatal period and early years
lay the foundation for a healthy life course, the learningand social skills we acquire at a young age provide thebasis for later development and support a strong national
polity and economy. High-quality services with universal
health-care coverage must be a top priority. The benefitsof investing in children would be enormous, and thecosts are not prohibitive: an analysis of the SDGs suggests
a financing gap of US$195 per person. To ensure stronger
economic and human development, each government
must assess how to mobilise funding using instrumentsthat help the poorest pro­portion of the population to meetthis gap for children, and frame these as the mostpowerful investments a society can make. But investments
are not just monetary: citizen participation and com­munity action, including the voices of children them­selves, are powerful forces for change that must be
mobilised to reach the SDGs. Social movements must
play a transformational role in demanding the rightsthat communities need to care for children and provide
for families.

Government has a duty of care and protection across all
sectors
Countries that support future generations put a highpriority on ensuring all children’s needs are met, by
delivering entitlements, such as paid parental leave, free
primary health care at the point of delivery, access tohealthy—and sufficient amounts of—food, state-fundedor subsidised education, and other social protection
measures. These countries make sure children grow up insafe and healthy environments, with clean water and air
and safe spaces to play. They respect the equal rights
of girls, boys, and those with non-conforming gender
identities. Policy makers in these countries are concernedwith the effect of all policies on all children, but especiallythose in poorer families and marginalised populations,starting by ensuring birth registration so that the govern­
ment can provide for children across the life course, andhelp them to become engaged and productive adultcitizens. The rights and entitlements of children areenshrined within the UN Convention on the Rights of theChild (CRC) ratified by all countries, except the USA.
Countries might provide these entitlements in different
ways, but their realisation is the only pathway for countries
to achieve the SDGs for children’s health and wellbeing,
and requires decisive and strong public action.
Since threats to child health and wellbeing originate inall sectors, a deliberately multisectoral approach is needed
to ensure children and adolescents survive and thrivefrom the ages of 0–18 years, today and in the future.
Investment in sectors beyond health and education—such as housing, agriculture, energy, and transport—are

www.thelancet.com Published online February 18, 2020 https://doi.org/10.1016/S0140-6736(19)32540-1

Published Online
February 18, 2020
https://doi.org/10.1016/
S0140-6736(19)32540-1*Commission co-chairs†Dr Bhan died in January, 2020
The Helen Clark Foundation,
Auckland, New Zealand(H Clark MA); Partnership for
Maternal Newborn & Child
Health, Geneva, Switzerland(H Clark); Senegal Presidency,
Dakar, Senegal(A M Coll-Seck MD); Departmentof Maternal Newborn Child andAdolescent Health(A Banerjee MD, N Rollins MD,
J Simon DSc), Department of
Health Systems Governanceand Financing, WHO, Geneva,
Switzerland (K Stenberg MSc);
Health Division (S Peterson MD,
D B Hipgrave PhD,J Requejo PhD), HIV, Data, andAnalytics Division UNICEF,
New York, NY, USA (J Requejo);
Department of International
Health, Johns Hopkins School of
Public Health, Baltimore, MD,
USA (S L Dalglish PhD,Y R Shawar PhD,Prof J Shiffman PhD); School of
Population Health,
University of Auckland,
Auckland, New Zealand(Prof S Ameratunga MBChB,P Reid MBChB); Department of
Global Health andDevelopment, London Schoolof Hygiene and Tropical
Medicine, London, UK(D Balabanova PhD,T Powell-Jackson PhD); Health
Systems Transformation
Platform, Tata Trusts, Mumbai,
India (M K Bhan MD); Centre for
Global Child Health, Hospitalfor Sick Children, Toronto, OT,
Canada (Prof Z A Bhutta PhD);
Global Financing Facility, World
Bank, Washington, DC, USA(J Borrazzo PhD, M Claeson MD);
Health Systems Research Unit,
South African Medical ResearchCouncil, Cape Town,
South Africa (Prof T Doherty PhD,

1

The Lancet Commissions

S S Rohde MPH); Department of
Health Management and Policy,(Prof F El-Jardali PhD) Knowledge
to Policy Center American
University of Beirut, Beirut,
Lebanon (Prof F El-Jardali,
R Saleh MPH); School of Public
Health, University of Western
Cape, Bellville, South Africa(Prof A S George DPhil);Financing Alliance for
Health, Nairobi, Kenya(A Gichaga MBChB); Institutefor Global Health (L Gram PhD,Prof D Osrin MRCPCH),
Department of Economics,(Prof I Rasul PhD) University
College London, London, UK(Prof A Costello FMedSci);
Health Policy and Systems
Research Consultant, Accra,
Ghana (A Kwamie PhD); China
Center for Health Development
Studies, Peking
University, Beijing, China(Prof Q Meng PhD); Program ofSocial Sciences and Health,
Latin American School of Social
Sciences, Buenos Aires,
Argentina (R Mercer MD);
Centre for Science andEnvironment, New Delhi, India(S Narain BA); Department ofMaternal and Child Health,
Uganda Ministry of Health,Kampala, Uganda(J Nsungwa-Sabiiti PhD);
Institute of Child Health,
University of Ibadan, Ibadan,
Nigeria (A O Olumide FWACP);
Department of Health Systems,
WHO, Phnom Penh, Cambodia(K Rasanathan FAFPHM);
West and Central Regional
Office, UNICEF, Dakar, Senegal(M Romedenne MPH); Pediatrics
and Clinical Epidemiology,
Sitaram Bhartia Institute of
Science and Research,
New Delhi, India(Prof H Singh Sachdev MD);Children’s Health andEnvironment Program,
The University of Queensland,
Brisbane, QLD, Australia(Prof P D Sly MD); Institute forLife Course Health Research,
Department of Global Health,Stellenbosch University,
Stellenbosch, South Africa(Prof M Tomlinson PhD); andNational Health Systems
Resource Centre, New Delhi,
India (R R Ved MPH)
Correspondence to:Prof Anthony Costello, Office of
the Vice-Provost, University
College London,
London WC1H 9BT, UK
anthony.costello@ucl.ac.uk

2

needed to address the greatest threats to child healthand wellbeing. Political commitment at executive levelis needed to coordinate across sectors and leveragesynergies across the life course, ensuring universal healthcoverage; good nutrition and food security for all;thoughtful urban planning; safe and affordable housing
and transport; clean energy for all; and equitable social
welfare policies. Multisectoral governance might takedifferent forms in each country, but it will require
strategic partnerships, cabinet-level coordination acrossministries, and management of diverse partners, withclear roles for each, including for non-state actors andthe private sector. Heads of state or prime ministers
must designate a cross-cutting government ministry or
equivalent to ensure joined-up action and budgeting forpro-child policies and to demand harmonised assistancefrom global stakeholders, whose support is currently
fragmented and inefficient.

Measure how children flourish today, but also how
countries’ greenhouse gas emissions are destroying
their future
Wealthy countries generally have better child health anddevelopment outcomes, but their historic and current
greenhouse gas emissions threaten the lives of allchildren. The ecological damage unleashed today endan­
gers the future of children’s lives on our planet, their only
home. As a result, our understanding of progress onchild health and wellbeing must give priority to measuresof ecological sustainability and equity to ensure we
protect all children, including the most vulnerable.
We assessed the feasibility of monitoring countries’
progress through a new child flourishing and futurespro­file, developed on the basis of survive and thrive SDG
indicators reported by 180 countries, territories, and areas(hereafter referred to as countries), and future threats tochildren’s wellbeing using the proxy of greenhouse gas
emissions by country. We also complemented the profile
with existing measures of economic equity. The poorest
countries have a long way to go towards supporting theirchildren’s ability to live healthy lives, but wealthiercountries threaten the future of all children throughcarbon pollution, on course to cause runaway climatechange and environmental disaster. Not a single country
performed well on all three measures of child flourishing,sustainability, and equity.
The SDG indicators already provide a strong foundation
for monitoring progress. However, we only found a verysmall amount of country data for the indicators used to
track child health and wellbeing, which all countries
agreed to collect. SDG monitoring needs a strong boost ininvestment to bridge the large data gaps in key indicators(with <50% of countries reporting data for many indi­cators), to allow for subnational disaggregation if govern­ments are to monitor, review, and act. To ensure ourchildren grow and flourish, we require timely and accurate
population data on health, nutrition, educational accessand performance, housing, and environmental security,
among other entitlements. Harnessing the power ofcitizen accountability mechanisms will be essential to fill
the data gaps. We also propose the development ofuser-friendly country dashboards to assess the effects onchild­ren’s wellbeing and sustainable development. Given
the urgency for action, regular reports on the SDGs to the
UN General Assembly must be the anchor of strong
advocacy on action for children everywhere.

Adopt a new protocol to the UN CRC to regulate againstcommercial harm to children
Although we recognise the role business plays in wealthand job creation, the commercial sector’s profit motive
poses many threats to child health and wellbeing, notleast the environmental damage unleashed by unregulatedindustry. More immediately, children around the world
are enormously exposed to advertising from business,
whose marketing techniques exploit their developmental
vulnerability and whose products can harm their healthand wellbeing. Companies make huge profits frommarketing products directly to children and promoting
addictive or unhealthy commodities, including fast foods,
sugar-sweetened beverages, alcohol, and tobacco, all ofwhich are major causes of non-communicable diseases.
Children’s large and growing online exposure, whilebringing benefits in terms of information access and social
support, also exposes them to exploitation, as well as tobullying, gambling, and grooming by criminals and sexual
abusers.
Industry self-regulation does not work, and the existing
global frameworks are not sufficient. A far stronger andmore comprehensive approach to regulation is required.
We call for the development of an Optional Protocol to
the CRC (ie, an additional component to the treaty thatmust be independently ratified), to protect children
from the marketing of tobacco, alcohol, formula milk,sugar-sweetened beverages, gambling, and poten­
tiallydamaging social media, and the inappropriate use of
their personal data. Countries who have led the way
in protecting children from the harms of commercial
marketing, supported by civil society, can support a
protocol for adoption by the UN General Assembly,
providing impetus for further legal and constitutional
protections for children at national level.
Children and young people are full of energy, ideas, andhope for the future. They are also angry at the state of theworld. Worldwide, school-children and young people
are protesting about environmental threats from fossil
fuel economies. We must find better ways to amplify
their voices and skills for the planet’s sustainable andhealthy future. The SDGs require governments to placechildren at the very centre of their plans to address thiscrisis. This Commission makes positive and opti­mistic
recommendations–but we have no time to lose, and no
excuses if we fail. A new global movement for child andadolescent health is today an urgent necessity.

www.thelancet.com Published online February 18, 2020 https://doi.org/10.1016/S0140-6736(19)32540-1

The Lancet Commissions

Introduction

Childhood is the ideal time to intervene

Prompted by the end of the Millennium Development
Goal era, with its focus on child survival, a Lancet
Commission to place children’s health and wellbeing at
the centre of the Sustainable Development Goals (SDGs)
was formed in 2018. The Commission was co-chaired
by Helen Clark, former Prime Minister of New Zealandand former Administrator of the UN Development
Programme, and Dr Awa Coll-Seck, Minister of State in
Senegal. The Commission aimed to consider the ways inwhich governments, medical professionals, and society
as a whole can accelerate progress on child health andwellbeing strategies in the context of the SDGs.
We can no longer consider child health and wellbeing
the prerogative of health professionals. Immunisation,
antibiotics, antenatal and delivery care, and goodquality health systems are of course essential,1 but weurgently need a broader plan to accelerate progress inareas previously neglected, such as early years dev­
elopment, adolescent health, and disability, and thedev­elopment of a coherent narrative to guide our work
across sectors. More immediately, we must respond toenvironmental and existential threats, which jeopard­ise the future for children on this planet. We requirea holistic view of the child, defined here as a person
aged 0–18 years old, whose wellbeing is at the centreof humanity.

Childhood is a special time of vulnerability but also ofopportunity. Pregnant women and girls are vulnerable tobiological and social risks that increase their susceptibility
to disease, disability, and preventable mortality. Inter­
ventions during pregnancy, childbirth, and infancy canhave a major effect on the health of both mother and child.
A healthy mother is a good outcome in and of itself; careand nutrition for mothers before and during pregnancy
contributes to the programming of a child’s healthy growthand development throughout their life course. Afterbirth, breastfeeding provides personalised medicine to thenewborn—a potent tool for improving health, if we canovercome the poor support for breastfeeding mothers andregulate the inappropriate promotion of formula milk
by a $70 billion industry.5 Interventions in the newborn
period and good newborn care can also prevent long-term
disability.6 We can do far more to support the 10% ofchildren with developmental delays and disabilities, who
require special care and attention; most of whom do notreceive the care they need.7 Providing such care will allow
these children to participate fully and equally, a huge gain
for society.
Evidence from longitudinal studies reports that thebenefits of healthy childhood development extend toolder ages: birth weight, infant growth, and peak physicaland cognitive capacities in childhood are associated withor predictive of older adults’ physical and cognitive capac­
ities, muscle strength, bone mass, lens opacity, hearing
capacity, skin thickness, and life expectancy.8–10 A metaanalysis of 16 independent studies concluded that a
1 SD advantage in cognitive test score assessed within
the first two decades of life is associated with a 24% lower
risk of death over a follow-up period of 17–69 years.11
Good nutrition in childhood is the basis for manysuch gains. Yet the so-called double burden of malnu­
trition means that overweight and obesity can coexist
with under­nourishment and micronutrient deficiencies
within a single population. WHO describes the rapid risein childhood obesity as “one of the most serious publichealth challenges of the 21st century.”12 The number ofobese children and adolescents increased ten times
from 11 million in 1975 to 124 million in 2016. In part,
urbanisation has increased access to junk food andreduced access to play areas and safe exercise spaces.
Our societies created these challenges—meaning it iswithin our power to reverse them.
The adolescent period (defined as children aged
10–18 years in this Commission) is another window ofopportunity, given its critical developmental timing interms of identity, agency, and vulnerability.13 In ado­lescence, patterns can be laid for a lifetime of poor
nutrition, reduced exercise, alcohol and tobacco use,
mental ill health, and interpersonal violence. Worldwide
10–20% of children and adolescents experience mental
disorders,14 but early intervention in this age group islargely absent—a huge opportunity to improve wellbeing“Our house is on fire”
Over the past 50 years we have seen dramatic
improvements in survival, education, and nutrition forchildren worldwide. Economic development, concerted
international action, and political commitment havebrought about rapid change. In many ways, now is
the best time for children to be alive,2 but economic
inequalities mean benefits are not shared by all, and all
children face an uncertain future. Climate disruption iscreating extreme risks from rising sea levels, extreme
weather events, water and food insecurity, heat stress,
emerging infectious diseases, and large-scale popula­tion migration.3 Rising inequalities and environmental
crises threaten political stability and risk international
conflict over access to resources. By 2030, 2·3 billion
people are projected to live in fragile or conflict-affected
contexts.4
Children have little voice in the shape of their future.
Decisions that will affect their lives are taken byparents, local leaders, governments, and global economic
decision makers, and by the captains of global cor­porations with enormous resources and purely commer­
cial interests. Environmental harm to children now and in
the future is intimately linked to our economic structuresand commercial activity. When youth climate activist
Greta Thunberg spoke at the World Economic Summit in
Davos, Switzerland, in January, 2019, she told delegates, “I
want you to act as you would in a crisis. I want you to act
as if our house is on fire. Because it is.”www.thelancet.com Published online February 18, 2020 https://doi.org/10.1016/S0140-6736(19)32540-1

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The Lancet Commissions

throughout a person’s lifespan. Adolescence presents an
ideal time for conversations about nutrition, exercise,mental health, relationships, drug use—such as smok­
ing, vaping, and alcohol consumption—domestic andgang violence, positive sexuality, and active and engaged
political citizenship. Yet little research has been done on
how to do so on a large scale.

Governance and voice
In the SDG era, country leadership requires a coherent
national vision of child wellbeing, a necessary precursor
to ensure aligned institutional frameworks and coor­dination mechanisms across ministries and sectors. Sucha framing is already proposed by the UN Convention on
the Rights of the Child (CRC), opened for signature in
1989 and ratified by all nations, except the USA. Yet socalled joined-up governance, which aims to coordinate
and implement policies across government,15 must
emerge from local realities, to ensure communication
across government departments, between a country’s
decision making centre and the most socially andpolitically isolated areas, and incorporate processes toensure citizens (including children) participate in govern­
mental decision making. Like the SDGs, strategies toimprove child health and wellbeing cannot succeed unlessthey are truly multisectoral. The home, work­place, andplaces of learning are all opportunities for convergenceof service delivery, but this will require significant
changes in governance driven by strong and focusedleadership.
Governance must also account for the fact that corp­
orate power to reach individuals has never been greater.
In our modern world, many multinational companies
have larger financial capitalisations than medium-sizedcountries—with 69 of the 100 richest entities on theplanet being corporations, not govern­ments.16 Addition­
ally, the rapid spread of sophisticated digital and mobile
commu­
nications means that children are exposed, as
never before, to a torrent of commercial marketingpressures from corporate powers. The power of big
business means government attempts to protect children
from harmful commercial behaviour requires agile
regulation, but this is often opposed by well-resourced
lawyers and lobby groups. Commercial governance isessential to protect children from alcohol, tobacco, andinsidious advertising which encourages formula feeding,junk-food diets, consumption of sugar-sweetened bever­ages, gambling, violent media and games, inappropriate
sexual behaviour, and other risks.

The Commission
This Commission reports on urgent and actionableagendas for our children’s future. First, we make the casefor putting child wellbeing at the centre of SDG policies.
Second, we describe what needs to be done: the packageof entitlements that governments and other stakeholders
should ensure each child receives, and the equity-focused4

investments and social mobilisation required to make it
happen. Third, we describe how global, national, andsubnational governance must be reconfigured to provide
strong multisectoral solutions. Fourth, we address theenormous challenge of com­mercial regulation in keep­
ing our children safe and healthy, and suggest new
approaches to protect them. Fifth, we review how coun­tries can build accountability through child-centred
SDG measurements, and the immediate top-down andbottom-up action required to track progress. Finally,
we offer 10 key recommendations to build a new global
movement for the health and wellbeing of children
and adolescents (panel 1). Although the scope andscale of our recommendations might seem daunting torich governments of high-income countries (HICs), letalone those that struggle to provide their citizens withbasic services, we believe positive change is possible atevery level.

Placing children at the centre of SDG policies
Concern for future generations is already at the centre of
the SDG endeavour. Here, we further theorise theconcept of sustainability around children’s health andwellbeing, and existing global frameworks, such as theSurvive-Thrive-Transform framework of the Global
Strategy for Women’s, Children’s and Adolescents’
Health (2016–2030).17 We also synthesise the evidence infavour of intervening in childhood to not only achieve
child health goals, but also derive key benefits throughout
the life course and for future generations. Finally, we set
the stage by identifying key messages for stakeholders
in all sectors, without whose collaboration child healthgoals cannot be met (panel 2).

Sustainability is for and about children
The threats to global health from disturbances inplanetary health are profound and imminent.3 More than
2 billion people, including half the world’s poorest
populations, live in countries where development out­
comes are affected by political fragility and conflict,problems increasingly linked with climate change.
In 2018, 1 billion people had moved or were on the move,with international migration increasing to 258 million
people.18 22 million of these people were refugees, with40 million people displaced by conflict, natural disasters,
or climate change, including many children.19 Even
under best-case scenarios, these numbers will increase
greatly as the face of the planet is remade by the effects ofclimate change.
In 2015, the world’s governments adopted 17 SDGs,
with 169 targets to achieve by 2030. The SDGs convey adual vision: to protect our planet from a dangerous anduncertain future and to ensure that we deliver secure,fair, and healthy lives for future generations. Children
are at the heart of this vision, with their own needs,
rights, perspectives, and contributions. They are thebridge to the future, and they demand our commitment

www.thelancet.com Published online February 18, 2020 https://doi.org/10.1016/S0140-6736(19)32540-1

The Lancet Commissions

Panel 1: Recommendations for placing children at the centre of the Sustainable Development Goals (SDGs)• Heads of state should create a high-level mechanism orassign one overarching department to coordinate work withand for children across sectors, create an enabling
environment to enact child-friendly policies, and assess theeffect of all policies on children• Heads of state and governments should create or designatea monitoring system to track budget allocations to child
wellbeing, using this process to mobilise domestic resources,by means of fiscal instruments that benefit the poorest insociety, for additional investment• Government officials at the relevant ministry, national
academics, and research institutions should develop strategies
to improve data reporting for SDG indicators measuring child
wellbeing, equity, and carbon emissions, using country
information systems and citizen-led data and accountability• Local government leaders should establish a cross-cutting
team to mobilise action for child health and wellbeing,
involving civil society, children themselves, and otherstakeholders as appropriate• UNICEF child-health ambassadors and other global
children’s advocates should mobilise governments andcommunities to adopt child-friendly wellbeing andsustainability policies, and advocate for rapid reductions inand accountability. Children are also the most vulnerable
to the lifelong environmental effects caused by climatechange arising from anthropogenic greenhouse gas
emissions, and from industry-linked pollution of the air,water, and land.20–22
Fundamentally, the SDGs are about the legacy webequeath to today’s children. For that reason alone,
children should be placed at the centre of the SDG
endeavour. The SDGs are the agreed-upon global frame­
work for working in the present to leave a legacy of ahealthy, sustainable planet and future for our children;
the UN Human Rights Council sees a clear link between
the SDGs and the CRC, which is the world’s most widely
ratified human rights treaty. The case for putting children
at the centre of the SDGs is based on their rights,
sustainable economic development, a life course approach
to wellbeing, and the notion of intergenerational justiceand fairness. Furthermore, making children the humanface of the SDGs helps us define progress towards
sustainability.
In a world where social inequalities and anti-immigrantfeeling are increasing and border walls are seen asa political solution, we need to build broader principles
of inclusion, including intergenerational ones. The
problems of the economy and environment are inher­
ently linked as the root of conflict in our societies. Unjust
economic policies have led to homelessness and hunger,even in the richest countries, as documented by the UN
Rapporteur on extreme poverty and human rights on
visits to the USA23 and the United Kingdom.24 Looking to

•

•

•

•

•

carbon emissions to preserve the planet for the next
generation
Leaders in children’s health, rights, and sustainability
should reframe their understanding of the SDGs as being
for and about children, and the threat to their future fromgreenhouse gas emissions, mainly by high-income
countries
Children should be given high-level platforms to share theirconcerns and ideas and to claim their rights to a healthy
future and planet
Country leaders on child health and child rights should push
for the adoption of new protocols by the UN Convention on
the Rights of the Child to protect children from harmfulcommercial practices
Country representatives to the UN should work together tocreate a simplified, effectively multisectoral UN architecture
to reduce fragmentation and siloes, and to put action forchildren at the centre of the SDGs
WHO and UNICEF leadership should meet with heads ofother UN agencies to plan coordinated action to support
countries to enact focused, effective policies to achieve theSDGs, and work with regional bodies to help countries toshare progress and best practices

Panel 2: Placing children at the centre of Sustainable
Development Goals policies—key messages• Sustainability, and the Sustainable Development Goals,
can be usefully conceptualised around action for thehealth and wellbeing of children• The health of children, and their future, is intimately
linked to the health of our planet• Interventions to improve health and wellbeing duringchildhood have immediate, long-term, andintergenerational benefits, which compound synergistically• The economic investment case for investing in children’s
health and education is irrefutable and is characterised byhigh benefit–cost ratios• Within government, all sectors have a role to play inimproving children’s health and wellbeing

the future, we emphasise the importance of humanitarian
responses, safety from violence and displacement, andprotection of children’s and human rights in all contexts.
Children are speaking out about their world, and weshare their concerns (panel 3). Children’s concerns about
their wellbeing focus on feelings of family together­ness, feeling safe, and enjoying healthy environments.
These principles must guide us when building a world
for this and the next generation of children. The con­sequences of not meeting our sustainability goals will fallupon children and young people—our most precious
resource—and individual citizens who deserve health,www.thelancet.com Published online February 18, 2020 https://doi.org/10.1016/S0140-6736(19)32540-1

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The Lancet Commissions

Panel 3: Children’s wellbeing in their own words

See Online for appendix

We asked children aged 6–18 years to describe what made themfeel happy and healthy in focus group discussions withindigenous Māori communities from rural New Zealand;
disadvantaged urban neighbourhoods in Lebanon; relatively
affluent communities from Ibadan, Nigeria; and very poor
communities from La Plata, Argentina (appendix pp 1–2).
In all settings, children cited key themes, such as family
togetherness, safety from violence, clean environments, andaccess to culture and education, as most important for
their happiness.
When asked about health and wellbeing, children cited theirfirst priority as: “the things that will keep me happy andcomfortable is that my parents love me and that we arecomplete in my family” (Nigeria), or “[being healthy is]playing with my whānau [extended family] and my mum
and dad” (New Zealand). Children often linked their own
happiness to the happiness of those around them, bothwithin loving and caring families and in their broader
neighbourhoods. “When other people are happy, we are
happy,” said a girl from Tyre, Lebanon. Children’s joy in life wasoften expressed in simple pleasures: as one hearing-impaired
child in Nigeria said, “It’s fun to be a kid because you haveopportunity to play.”Children were very sensitive to their environments, both within
their homes (a “warm dry house” in New Zealand) and theirlocal environment, which they sometimes described as marredby trash, noise, exhaust, pollution, or other contaminants.
In Argentina, teenagers mentioned dogs and rats as threats totheir health, and they were disturbed by garbage dumps.

wellbeing, and a planet capable of sustaining life into
the future.
We take a life course-based approach, from precon­
ception to adolescence, which makes the link to inter­
generationality because the health and wellbeing ofchildren is linked to that of their parents and otherindividuals making up their society, and their own futurechildren and grandchildren. Children’s specific factors ofvulnerability, and protective factors across their life course
are represented in the upper part (protective) and lower
part (vulnerability) of our model (figure 1). The equity gap
or gradient is represented by the distance between upperand lower curves, affected by the social and environmental
determinants of health to the right of the gap arrow. Whilethe equity gap is intergenerational in its mode of social
reproduction, the smaller starting point in the early stagesof life reflects the evidence that early childhood is a good
window of oppor­tunity to intervene and break the cycle ofintergenerational poverty. Finally, the rights approach isshown by the upper curve, using a life course approachand incorporating the four foundational principles of the
CRC. Thus, child wellbeing is anchored in rights andequity across their life course, with the aim of enhancing
protective factors and mitigating vulnerability. The model
6

Children and youth often mentioned the desire to participate
in cleaning up their local environments whether by clearing
brush (Nigeria), cleaning up the beach (New Zealand),sweeping the roads (Lebanon), or generally “improving thecountry” (Argentina).
Children said their wellbeing was threatened by violence.
In insecure environments, children frequently recounted being
scared at witnessing violence, such as fights, shootings, or fatal
car or motorcycle accidents. Drug use, absence of security,and prevalence of robberies was mentioned as an issue ofcommunity cohesion, as in Argentina: “If they know you, there
is generally no violence against you. When people know eachother, there is less violence.” But in other cases, children spokeof being beaten or hit in their homes and said this was wrong:“[parents] should not be harsh on them; it is child abuse forsmall small children” (Nigeria). Often children worried about
being bullied, sometimes for their religion, ethnicity, or
nationality, or being sexually harassed.
Finally, children often cited a desire to attend school and learn
about and participate in their culture. They said children should
not have to work or marry: “Children should be in school,
learning” (Nigeria). In Argentina, teenagers said schools gavethem the information they needed to make the right choices inlife and improved their mental health through art and music.
Indigenous children from New Zealand also emphasised theirconnection to their culture (“Te Ao Māori”—the Maori world)
and the importance of speaking their language and learning
about traditions of song and storytelling. “It feels special when
you’re Māori,” said one child.

also shows the inseparability of the agendas to promotewomen’s and child’s rights, health, and wellbeing, as put
forth in the Global Strategy on Women’s and Children’s
Health (2016–2030),17 whose objec­
tives and targets arealigned with the SDGs.

Intervening in childhood has lifelong, intergenerational
benefits“An ounce of prevention is better than a pound of cure,”
said Benjamin Franklin, and a rich body of theoreticaland empirical literature describes how interventions
in early childhood generate higher returns than remedialactions later in life. Early childhood, when brain plas­ticity
and neurogenesis are intense, is a vital period forcognitive and psychosocial skill development.25 Decadesof developmental psychology research have reported
the highly interactive process through which children
develop the cognitive, social, and emotional capacities
that are foundational for school achievement and adulteconomic productivity.26 Investments and experiences
during the early childhood period create the foundations
for lifetime success.
Early investment should start before birth because the
9 months in utero is an essential period and conditions

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The Lancet Commissions

Healthy development

Child rights to survive, thrive, and participate with no exposure to discrimination and bestinterests at heart, and protected sexual and reproductive rights

Protective factors

Skilled birthattendant
Responsive
careBirth Immunisations
Schoolregistration
Support for achievement
early childdevelopment

Social andgroup
support

Universal
accessICT
to SRH
literacy

Safe learning
environments

Parity ineducation

Social andenvironmental
determinants(embedding)Intergenerational
effect fromparents

Child development
equity gap at
adulthood

Equity gap
preconception
Maternal
deprivation

Vulnerability factors

Neonatal risks:• Low birthweight• Prematurity

Malnutritionand poor
growthChild Commercial Child Adolescentlabour exploitation marriage birth

Exposure to physical, sexual, and psychological violenceLife course

Birth
Preconception

Pregnancy

Newborn

InfancyChildhood

Adolescence and adulthood

Figure 1: Sustainable Development Goals measuring protective and risk factors for child wellbeing across the life course
ICT=information communication technology. SRH=sexual and reproductive health.

during pregnancy shape the future trajectory of abilities
and health.27 Before pregnancy, women and adol­escent
girls should receive nutritional and counselling inter­
ventions to ensure they are healthy and equipped to makedecisions about whether and when to become mothers.
Maternal health interventions are critical to prevent,detect, and treat problems early during pregnancy andensure women have access to high-quality care in case ofcomplications. Food and iodine supplementation before
or during pregnancy and antenatal corticosteroids for
women at risk of preterm birth in HICs have bene­ficial
effects on child develop­
ment.28,29 Smoking cessation
during pregnancy, which can be supported by psychosocial
programmes, also reduces low birthweight, and preterm
births30—outcomes strongly related to improving earlychildhood development. Research has also shown thedevelop­mental origins of adult diseases like diabetes,
heart attacks, and strokes.31,32 Prenatal exposure to envir­
onmental contaminants is associ­ated with epigenetic
changes, such as DNA-methylation, linked to the develop­
ment of diseases later in life.33 For example, studies
in Sweden on the radioactive fallout following the acci­
dent at the Chernobyl nuclear power plant, Pripyat,
Ukraine, show that in-utero exposure affected educational
attainment and income many years later.34 Economists’work on fetal exposures has also suggested long-term
economic effects, including reduced test scores andearnings.35

Fetal and early-life nutrition is also essential for longterm health, cognitive development, and economic out­
comes.36,37 Poor fetal growth or stunting in the first 2 yearsof life leads to irreversible damage, including reduced
adult height, lower attained schooling, and lower adult
income. Children who are undernourished in the first
2 years of life and who put on weight rapidly later inchildhood or in adolescence are at high risk of obesity andlater chronic diseases, such as diabetes, heart attack, andstroke.37 Early-life nutritional interventions, such as thepromotion of breastfeeding and iodine sup­plementa­tion, consistently show benefit-cost ratios that exceed
one.38 Improv­
ing gender equality also has benefits forchild nutri­­tion, and is an independent predictor of childmalnutrition and mortality in cross-country comparisons.39
Yet an estimated 250 million children younger than
5 years old in low and middle-income countries (LMICs)
are at risk of not reaching their developmental potential.40
At the same time, we know what children need for healthy
development: nurturing and responsive care to promote
their health, nutrition, security, safety, and opportun­
ities for early learning.41 Children with dis­abilities or an
impairment of functioning require screening and earlyinterventions so that they too can reach their full potential.
Follow-up studies of children exposed to poverty, from awide range of countries, show the beneficial effects ofearly childhood inter­ventions for adult earnings, cogni­
tive and educational achievement, health biomarkers,

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7

The Lancet Commissions

reductions in violence, reduction of depressive symp­
toms and social inhibition, and growth (eg, increasing
birthweight and head circumfrence) in the subsequent
generation.40
In Jamaica, 2 years of psychosocial stimulation to
growth-stunted toddlers increased earnings by 25%
20 years later, sufficient to catch up with individuals who
were not stunted as children.42 In the USA, the HighScope
Perry Preschool programme had estimated annual social
rates of return of 7–12% meaning that every dollar invested
resulted in $7–12 benefit per person.43,44 Much of the effects
in adulthood come from changes in personality traits,
such as academ­ic motivation and aggressive behaviours,
as opposed to cognitive improvements.45 In making the
economic case for early childhood interventions, wider
benefits to society have been reported, including reduc­tions in crime.46 The benefits are personal, societal,
and intergenerational: a recent analysis of wide-scale
school construction in Indonesia between 1973 and1979 found that increased parental education benefitedchildren through increased household income, better
living standards and housing, and paying higher taxes.47
An increasing amount of evidence shows the synergistic
benefits of interventions in early years being followed bylater interventions in middle childhood and adolescence,
particularly in popu­
lations who are exposed to highdevelopmental risk.48
Life course investment frameworks highlight the socalled dynamic complementarities of human capability
and the role of self-productivity.49 Capabilities learnt earlyin life provide the foundation for increasing the
productivity of investments later in life. In other words,
investments at different stages of life are synergistic.
Self-productivity refers to the idea that capabilities are
self-reinforcing, for example better health promotes
learning. Together, dynamic complementarity and selfproductivity produce multiplier effects through which
capabilities beget capabilities. Such frameworks provide
a strong rationale to invest in early childhood, and tokeep investing into middle childhood and adolescence.

Investments in children’s health and education arehighly cost-effective
Health is of value in its own right. People place greatvalue on living longer, healthier lives. Parents prioritise
the health of their children. In surveys around the world,
health is typically found to be one of the most important
determinants of happiness and life satisfaction.50
An extensive body of evidence reports on the costeffectiveness of health interventions for children.48,49
Scaling up integrated maternal, newborn, and child healthpackages to 90% coverage in 75 countries in which morethan 95% of the world’s maternal and child deaths occur
could avert 849 000 stillbirths, 1 498 000 neonatal deaths,
and 1 515 000 additional child deaths.51 Increasing access tosuch packages is essential because complications fromprematurity, intrapartum-related events, and infectious
8diseases—such as pneumonia—remain the leading
causes of death in child­ren younger than 5 years old.53
Intervening early costs less than attempts to compensate
for early deficits with remedial interventions at older
ages.41 An analysis, pub­lished in 2017, suggests that thecost of inaction for not improving child development
through universal preschool and home visits, andreducing stunting, is sub­stantial and could reach morethan 10% of gross domestic product (GDP).54
Global investment cases that estimate the benefit-cost
ratio of investing in health and other sectors are
summarised in figure 2. Translating health gains intomonetary values is challenging from an ethical and amethodological perspective, and can be done in multiple
ways.55 Although no shared con­sensus exists, estimatesvalue a year of life in LMICs in the range of 1·5–2·3-times
GDP per capita.56,57 Using the more conservative value of
1·5, analyses suggest that the economic (eg, productivity)and social benefits (eg, health) of expanding a set of
integrated interventions for women’s and children’s healthare 7·2-times more than the costs in low-income countries(LICs) and 11·3-times greater in lower-middle income
countries.58 Valuing a year of life at 2·3-times GDP per
capita, The Lancet Commission on investing in healthproduced higher benefit-cost ratios for a similar set of
health interventions.56
Studies into global investment for education, founded
on a wealth of evidence,59 show that each $1 invested in
edu­
cation will generate an additional $5·2 of benefits
through increased earnings in LICs and $2·5 of benefits inlower-middle income countries (figure 2). These benefitcost ratios almost double when the health bene­fits—
reduced adult and child mortality—of improving edu­cation
are taken into account. Incorporating the monetary valueof reductions in mortality means each $1 invested in
education will generate an additional $9·9 of benefits
in LICs and $3·7 of benefits in lower-middle income
countries. These benefits could be an underestimate, giventhat studies show a range of other benefits of high-quality
education on sexual and reproductive health, mental
health, reduced risk of non-communicable diseases laterin life, reduced tobacco smoking and drug use, and fewer
incidents of violence.60
To thrive at school, children must be healthy and wellnourished. A powerful economic argument for targetingthe health and development of school-age children is thatit promotes learning during their only opportunity foreducation.61 Ill health and poor nutritional status impair
learning. For example, malaria and worm infections
reduce school attendance and are a leading cause ofanaemia, which can negatively affect cognition andsustained attention.62,63 Health interventions to prevent or
treat infectious disease can have a positive effect onlearning and in turn generate long-term economic bene­fits
in the form of higher earnings.62,64–67 These synergies
suggest that health and education are two sides of thesame coin. A global investment case for adolescents68

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The Lancet Commissions

Adolescent health(low income)

Scale

12·6

20 BCR

Adolescentwellbeing

Adolescenteducation(low income)
11·0

15 BCR
Adolescent child marriage(low income)
6·9
Adolescent transport(low income)
6·6

Water andsanitation

10 BCR

5 BCR
Basic sanitation (low-income and middle-income countries) 2·920

Health(lower-middle
income)Basic drinking water
3·3(low-income and middle-income countries)
Eliminate open defecation
5·8(low-income and middle-income countries)

Health9·0 (low income)1·5

Health

Education(upper-middle
income) 3·8
Education(lower-middle
income)Education

10·0
Education(low income)

7·2
Maternal
6·1
Maternal and and child health(low income)child health(upper-middle
income)11·3
Maternal andchild health(lower-middle
income)Maternal andchild health

Figure 2: Benefit-cost ratios: returns on every US dollar invested
BCR=benefit-cost ratio. LMIC=low and middle-income countries. MCH=maternal and child health. A benefit-cost ratio of one (grey circle) indicates costs and benefits
are the same. A ratio of more than one indicates that the benefits are more than the costs. Each concentric ring equals a BCR of 10. The majority of countries excluded
are high-income countries with some exceptions. The figure shows high returns to investment in children’s health and wellbeing across a variety of domains. BCR iscalculated by dividing the monetary benefit of an intervention by the monetary cost of implmenting it.

shows that investing in strategies to reduce child marriage
and road accidents will also generate benefits that far
exceed costs (figure 2). Although no analogous benefit-cost
ratio calculations exist outside the health and education
sectors, interventions in all sectors are widely understood
to be investments in current and future societal outcomes,
rather than just spending.

All sectors are responsible for children’s wellbeing
Sectors beyond health and education can, and must, work
to improve the health and educational attainment ofchildren, to capture valued societal and economic benefits.
The socioecologic environment in which children live canbe seen as a series of concentric circles.69 At the centre is
the home, surrounded by its immediate environs, locality,
and wider urban or rural area. Each of these circles
balances opportunity with exposure and constraint. In
the home, potentially harmful exposures include indoor
air pollution, tainted water and inadequate sanitation,
overcrowding, excessive cold or heat, damp and mould,
domestic hazards from accident or violence, electri­
city, burns, noise, fire, flood, earthquake, environmental
toxins, and hazardous location (eg, close to water bodies,
dumping grounds, railway tracks, or roads). Children

might also be exposed to alcohol use and abuse, secondhand tobacco smoke, and unhealthy diets, with links tofood policy and regulatory schemes upon which families
have little direct influence.
Good housing is essential. The rush to urbanisation
has created a planet of slums. Informal settlements,
in which approximately 40% of the world’s children
currently live, intensify many of the previously men­tioned threats through a combination of substandard
housing or illegal and inadequate building structures.
Residents face overcrowding and high density, unhealthyliving conditions and hazardous location, poor accessto basic services, poverty and social exclusion, andinsecurity of tenure.70 Although we have too few locallydisaggregated data,71 we require no more evidence thatthese exposures and constraints have harmful effects
on child health. Furthermore, the common divisionof house­hold labour means that the greatest burdenof indoor air pollution from burning of biomass fuels isborne by women and children.72 Meanwhile, access toclean water and adequate sanitation is rare in suchsettings, despite being one of the most effective publichealth interventions a society can provide to improvehealth and wellbeing.

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9

The Lancet Commissions

Harmful exposures related to the environment outside
the home include air pollution, vehicular and pedestrian
accidents, crime and violence, and urban heat islands(created by heat-retaining land surfaces). Opportunityand constraint centre on shops, schools, and otherservices, such as health care, transport, exercise, andgreen space. There is good evidence for associations
between exposure to air pollution and intrauterine growth
restriction and poor childhood respiratory health.72–74
In terms of constraint, important concerns for childhealth include neuropsychological development, the foodenviro­nment, insufficient active transport and oppor­
tunities for exercise, and traffic accidents. One area thatmerits special attention is road safety because road injury
is the leading cause of death for children and young
people aged 5–29 years.75 Interventions to improve roadsafety are simple and relatively uncontroversial andinclude speed restrictions, mandating the use of seatbelts and helmets, and strong penalties for driving under
the influence of drugs and alcohol, but enforcement
remains a challenge.
Only a small amount of research on the effects of thesurrounding neighbourhood on early child development
has been done.76,77 Neighbourhoods with amenities, such as
libraries, schools, and recreation centres, are positively
associated with child physical health, social competence,
and wellbeing, and negatively with vulnerability todevelopmental delay.78 UNICEF frames the idea of a childfriendly city within the UN CRC.79 Urban planners havebeen attempting to modify the physical environment toincrease exercise through walkability, leisure oppor­tunities,
and active transport.80 Intuitively, and with some evidence,children’s physical activity increases with access to safe
roads, parks, and recreation areas, and decreases with trafficand crime exposure.81,82 The idea of playability as a stimulus
to exercise is receiving interest.83 Children have a right toplay,84 and require spaces to do so. Neighbourhoods that areprotected from traffic and have green spaces are more
conducive to outdoor play and physical activity.78 Some
evidence shows a positive effect of green space on cognitive
development and mental health,85,86 and that green space isassociated with improved obesity-related health indicators.87
Given concerns about non-communicable diseases andobesogenic environments, modifying the food environ­ment
and increasing exercise are urgent, but the evidence basefor action is small.88
Child health intersects inescapably with the planetary
health and non-communicable disease agendas in thelocal commu­nity. Street connectivity, appropriate hous­ing density, and walkability are win-win aspirations forhealth and the environment, but direct links with childhealth have been difficult to show.74 People want environ­ments safe from air and toxic pollution, road traffic
accidents, crime and violence, places that offer social
inter­action, walkability and playability, and a range ofservices and amenities that have benefits for both healthand envir­onment. For example, traffic calming, and the10existence of playgrounds are associated with both more
walking and less pedestrian injury.89
For both planetary sustainability and child wellbeing,clean energy remains a huge development challenge. In
2016, around 3 billion people (1·9 billion in developing
countries in Asia and 850 million in sub-Saharan Africa)
were without clean cooking fuel or technologies, creat­ing harmful indoor air pollution estimated to cause
3·8 million deaths per year.3,90 The number of people
without access to electricity fell from 1·7 billion in2000 to 1·1 billion in 2016; however, most of the newly
accessed electricity was generated with fossil fuels, a
key challenge for decarbonised energy systems. Elec­tricity growth in China and India is largely driven bycoal-generated power stations; coal remains the main
fuel used for electricity production worldwide, at
37% of the total.91 A shift of investment towards clean
energy technologies is happening, with accelerating
growth in new low-carbon power generation, but overall
global energy-sector carbon emissions remain largely
unchanged.3
Energy and the industrial sector are linked inextricablywith air pollution. Exposure to polluted air prenatally andduring early postnatal life is associated with an increased
risk of acute respiratory diseases in childhood, withconsiderable morbidity and mortality.92,93 Furthermore, air
pollution exposure impairs lung growth and reduces lungfunction;92 increases the risk of cardiovascular disease,94
obesity,95 type 2 diabetes, and metabolic syndrome;96
slows brain maturation; and impairs growth in cognitive
function in schoolchildren.97,98 Emerging evidence alsosuggests statistically significant effects of air pollution on
intelligence quotient (IQ);99 one study reports a four-point
drop in IQ by the age of 5-years in a sample of children
exposed to polluted air in utero.100 Reducing air pollu­
tion can quickly improve children’s health: for example,
effective reduction of air pollutants in Southern California
through legislation resulted in increased lung function
growth and reduced respiratory symptoms in children.101,102
However, regulation is compli­cated by the fact that air
pollution can be a transnational issue (eg, spill-over ofpollution between China and South Korea was associatedwith increased mortality from respiratory and cardio­
vascular diseases in South Koreans, including children
younger than 5 years old).103 Pollution control would
improve child wellbeing, with children living in LMICs
having the most to gain.

Summary
We have provided a rationale for placing children at thevery centre of the SDGs and reviewed medical, publichealth, and economic arguments in favour of investing
early in children’s health and wellbeing, across all
sectors. We now turn to the issue of children’s entitle­
ments, and how to deliver them, as a way of operational­
ising a new global movement for children’s health andwellbeing.

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The Lancet Commissions

How to ensure that children receive theirentitlements?
Putting children at the centre of the SDG agenda will
enhance our drive for sustainable development. Here,
we define the actions needed to achieve this agenda bylaying out a set of entitlements for children and detail the
responsibility of families, communities, and governments,
required to deliver them (panel 4).

What entitlements and rights should children expect?
Placing the SDGs in the service of children involves
building on a legacy of commitments to human rights,
beginning with the Universal Declaration on Human
Rights, adopted by the UN General Assembly more than
70 years ago, that outline the inalienable entitlements of all
people, at all times and in all places, as a foundation for
freedom, justice, and peace in the world. The CRC, which
recog­nises and affirms children’s rights specifically, turned
30 years old in November, 2019. In many ways the CRC
was a precursor of the SDG framework.104 The CRC iscomprehensive, and not only states children’s rights topreventive, promotive, and curative health care, “… but
also to a right to grow and develop to their full potential”.105
The CRC further declares that all children (aged 0–18 years)
are entitled to survival, protection, development, andparticipation.
Every UN member state (except for the USA) is party to
the CRC, which provides the foundation for the rights ofchildren. As a convention it is legally binding; as a result,it goes beyond the voluntary SDG framework. Whileindividual countries have turned the CRC into law and aim
to report once every five years on the fulfilment of the CRC
to the UN Committee on the Rights of the Child (Austria,
Australia, Belarus, El Salvador, Mozambique, Rwanda,
Tonga, Tuvalu, and Sri Lanka reported in 2018, with
17 other countries reporting in 2017),106 the CRC has yet tobe widely used to advocate for children in the context of the
SDGs. Violations of children’s rights are common across
many domains, such as poverty; inadequate nutrition;
violence and war; gender bias and discrimination against
sexual minor­
ities; poor access to clean water, shelter,
education, and health services; and climate degradation
and unsustain­able use of planetary resources.
The Convention is a legal document that commits
governments to fulfil the rights of all children living within
their country. We extrapolate that an inclusive set ofentitlements for children in the SDG era can be articulated
and monitored, expanding the CRC’s accountability
framework to provide regular reporting of their fulfilment.
The general comments to the CRC, considered authoritativeinterpretations of the rights articulated therein, provide thebasis for this package of entitlements. The entitlements areorganised across five over-arching rights and presented
according to a continuum of children’s ages (many of
the rights apply to all children aged 0–18 years; figure 3).
Because the entitlements are based on rights, granting
them is not optional, although countries might use

Panel 4: Ensuring children receive their entitlements—
key messages• Children’s rights and entitlements are comprehensively
defined by international treaties, including the Convention
on the Rights of the Child, which are widely ratified• Children are key stakeholders in an interconnected web ofrights and responsibilities, which binds humanity together
and to our planet in a shared endeavour of mutual care
• Children have a right to claim their entitlements andparticipate in discussions about how to deliver them
• Families can best provide nurturing care for children
when the rights of their mothers and other caregivers
are realised• Communities are powerful forces for positive change inchildren’s lives, especially when society allows for equitableparticipation• Governments must do much more in terms of publicfinancing of services, effective delivery, and equitablesocial protection, adequately financed to meet the
Sustainable Development Goals

different policies or interventions to deliver them. Of note,one of the key prerequisites for these entitlements to bedelivered is birth registration, yet a quarter of children
younger than 5 years old worldwide are not registered.107
In many documents, including this Commission,
children are defined by age group and their absoluteor relative dependency on adult care, protection, andadvocacy. However, in the sense that we all have (or havehad) parents or caretakers, we are all children and exist
in a set of relationships with corresponding rights andresponsibilities. First, across families through timeand genera­tions—from ancestors, grandparents, parents
and to future generations; second, within communities
across geography and social place—where our families are
from, our homelands, and our ways of life; third, in
relation to local and national governments—where key
services are planned, budgeted for, and coordinated, andbodies are empowered to guarantee rights, and where
nations work together on transnational issues; finally,embedded within our environment—from the planet, tosources of food, water, and air, and places where we lay thedead to rest.
These dynamic relationships have parallels in how rights
and responsibilities are balanced across society in order to
respond to the entitlements of us all as children. We
previously discussed our responsibility to protect andpreserve our planet for children’s present and future
wellbeing. We now examine how children, families, com­munities, and governments, can help to fulfil children’s
entitlements under the CRC.

The pre-eminent role of children and families
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The Lancet Commissions

by 18 years of age they are optimally healthy, educated,engaged in productive citizenship, and act as stewardsof the Earth. Families are the immediate environ­ments
in which children are born, grow, play, learn, andcontribute.

Involving children’s voices in policies and programmes
As children develop, they ideally increase their “sub­stantive freedom… to achieve valuable functionings”108
Be protected

Be educated• Adequate standard of living• Free primary education• Safe, supportive, and nurturing family • High-quality and safe
• Safe leisure and play facilities
primary schools• Violence free home
• Specific early childhood• Regulated media and protection fromeducation for children
inappropriate and offensive material
with disabilities• Safeguarded from abuse and neglect, • Child-centred and childand alternative, affectionate carefriendly education
provided (if required)• Inclusive education and• Free from violence and exploitation
schools that are physically(physical, mental, and neglect)and culturally accessible• Free from harmful and exploitative• Education about respect
work, including sexual exploitation
for natural environment• Minimum age of criminaland sustainable
responsibility at 14 years olddevelopment• Safe and adequate housing• Schools that are free from
• Violence free school and community
and that challenge• No death penalty or life imprisonment discrimination
without parole• Education about and• Regulation of online and recreational
challenging racism
material and age classification of• Human rights education
media, broadcasting, and films• Promotion of values of• Online safety information regarding
human rights
cyber-bullying, grooming, trafficking, • Life-skills educationand sexual abuse and exploitation,
promoting healthy
and information on where to accessbehaviour, including
help
personal hygiene, stress• Regulation of fast foods marketing
management, nutrition,• Protection, care, and proper treatment, and self-careincluding guardian and legal• Community-based
representation, of unaccompanied and education challenging
separated children
gender roles and stereo• Unaccompanied and separated migrant types and harmful
or refugee children not to be returned to practices
a country with a substantial risk of harm • Schools with well
• Protection from economic and sexualfunctioning and safe
exploitation
facilities• State should attempt to preserve the • Time and space forfamily unit in the case of childage-specific and inclusive
protection systems, including in theplay and creativity
context of migration• Time with peers and social• Controlling of firearms
activities• Restricted access to alcohol and drugs • Time for rest and leisureand regulation of advertising• Access to digital media• Protection from harmful traditional
and the internet, including
practices and violence
online safety education• Laws and standards relating to business and legislation and laws
and labour, employment, health andto tackle online abusesafety, environment, taxation, and• High-quality andanticorruption
accessible secondary• No immigration detention
schools• Legal minimum age of consent,• Vocational guidance andregardless of gender; not specified for
information
sexual and medical treatment consent; • Drug, alcohol, andto be a minimum of 18 years for
substance use education
marriage, armed forces recruitment,• Sexual health education
and alcohol and drug use• HIV/AIDs education and• Protection and standards for children
informationof working age in businesses• Road safety and driving• Protection from armed forces andeducation
gang recruitment

Be healthy

in society. Recognition is growing that promoting
meaningful participation of children con­tributes toimproved social cohesion, more egalitarian communities,
and helps adolescents make a better informed, healt­hier, and more empowered transition into adulthood.13
Furthermore the CRC stipulates children’s right to be
involved in decisions and actions that affect them, tobe able to express their views, which are then duly rec­ognised by adults. The UN affirms that only by engaging
Be treated fairly

Be heard• Parenting education and counselling services• Access to health care, education, protection,• Have a name and nationality• Prenatal and postnatal health careand services without birth registration• Birth registration• New born care
• Specific measures to ensure birth registration• Responsive parenting• HIV/AIDS counselling, testing, and treatment forfor vulnerable and marginalised groups,• Preserve identity
mothers and babies
including children with disabilities, indigenous • Free late birth certificates• Exclusive breastfeeding for children younger thanchildren, and children in street situations
and civil registration
6 months old, and alongside complementary• Support for parents of children with disabilities • Feedback and input onfoods until 2 years, except in cases of HIV-infected • Free from discrimination, including children
educationmothers where replacement feeding iswith disabilities, indigenous children, LGBT• Sufficient and effective ways
recommended if feasible
children, migrant children, children in theto report abuse or violence• Immunisation, antibiotics, and antiviral drugs
juvenile justice system, and HIV/AIDS affected• Express views freely and be• Child-care services, maternity protection andchildrenlistened to in schools and byfacilities• Access to education for girls
families and the community• High standard of health care
• Educational and economic opportunities for girls • Know own rights• High-quality and accessible primary, secondary,• Education free from discrimination and barriers• Express views in any
and tertiary health carefor marginalised groups
decisions affecting them
• Early detection of disabilities, intervention,• Equal right to education, health care, and• Child-friendly, agetreatment and rehabilitation, and physical aids
standard of living for marginalised children,
sensitive, safe, and• Clean drinking water
including unaccompanied and separated
voluntary ways to express• Good nutritionchildren, migrant and refugee children, children
views in decision making• Adequate sanitationin street situations, and children with disabilities • Access to sensitive advice,• Specialist health care for children affected by• Vulnerabilities taken into account when looking advocacy and complaints
substance abuse (eg, mothers affected by alcoholat best interest
procedures relating toor drug substance abuse and risk of early initiation • Separate juvenile justice system focusing on
corporal punishment,
to substance abuse)rehabilitation and restorative justice, withdisability discrimination,• Information and advice on personal wellbeing andeducation, medical care, leisure time, andjuvenile justice, violation
physical and mental health, both in and out ofcontact with family and communityof rights by businesses andschool, through the media and youth, religious,• Specific focus on protection for marginalised or
migrationand community groups
vulnerable groups from economic and sexual• To be heard and effectively• Mental health services, treatment, andexploitation and violence, including HIV/AIDS
participate throughout therehabilitation
affected children, children in street situations,process of juvenile justice• No age limit on confidential counselling and advice children with disabilities, and migrant children • Involvement in decision
without parental consent, regarding the child’s• Special measures for groups who are marginalised making, policies,
safety or wellbeing (distinct from giving medicalor hard to reach in order to realise their rights
programmes, andconsent)• Specific measures for those with intersecting
procedures, relating to• Specific health information, guidance, andand multiple vulnerabilities
HIV/AIDS policies,
counselling, including for children with disabilities • Conservation, development and promotion of
disabilities, healthand gender specificcultural traditions for minority, refugee, andprovisions, harmful• Sexual and reproductive health information andindigenous groups, including names, families,
practices and genderservices, including contraception and safe abortion and language
discrimination, indigenous• Affordable, accessible, voluntary, and confidential • Free from negative stereotypes aboutchildren, children in street
HIV/AIDS prevention, care, treatment, and support adolescencesituations, immigration• HIV/AIDS education and information• Free to express sexuality and gender identityand asylum process,• Specific HIV/AIDS services and information for• Free to practise religion
education, health, economy,
vulnerable and discriminated against groups• Support for adolescents in care, including
environment, and care
• Human papillomavirus vaccinations for girls
reviews of their situations and support for• Adolescents express views• Confidential HIV testing and counselling services,education, and help for leaving care in gaining
on matters that concern
particularly for vulnerable and marginalised groups, employment, housing, and psychological support them and safe andincluding girls and LGBT adolescents• Culturally sensitive and appropriate services foraccessible complaints• Sexual and reproductive health information andindigenous children, relating to health,
procedures
services, including contraception, family planning,education, nutrition, recreational sports, socialand safe abortion services
services, housing, sanitation, and juvenile justice• Right to privacy and confidentiality regarding• Support for adolescent mothers, fathers, andmedical information, advice, and counselling
carers, including help to stay in education• To give consent for medical treatment, as well as• Treated equally before the law, including
parents or guardians, and, if of sufficient maturity,vulnerable and discriminated against groups
give sole consent without parental consent• Children younger than 18 years to be treated in(age not specified)accordance with the rules of juvenile justice• Services and support for adolescents withdisabilities, minority and indigenous adolescents• Removal of criminal record at 18 years of age

Figure 3: Summary of child entitlements as laid out in the General Comments to the Convention on the Rights of the Child12

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The Lancet Commissions

Panel 5: Case study: U-Report
U-Report is a free global platform open to individuals of any age.
As of 2019, 28% of U-reporters worldwide are under the age of
20 years and 39% are between 20 and 24 years; 44% of allreporters are female.
U-Report aims to encourage community participation,
especially by youth, in a wide range of issues including health,education, water, sanitation and hygiene, youth
unemployment, and HIV/AIDS and disease outbreaks throughmobile technology and social media. Started through UNICEF
funding in 2011 in Uganda, U-Report draws on the opportunity
provided by widespread use of mobile technology to enable
youth to voice their opinions.
U-Report uses messenger polls and alerts sent via direct
message combined with real-time responses that are mappedon a website. Responses can be disaggregated by region, gender,
and age group enabling policy makers to have insights into theneeds and opinions of specific groups. Cross-country polls havebeen used to gather data on issues affecting youth across all
participating countries, such as school bullying and universal
health coverage.
In 2019, 50 mostly low-income and middle-income countries
have U-report programmes worldwide, with almost 6 million
subscribers. The UNICEF team analyses and interprets the
responses to messenger polls and shares the results withnational policy makers and on the country U-Report websites;
following which action can be taken.

managers have used it to strengthen immunisation
campaigns and use the programme as an early warning
system for health system challenges, such as drug shortages.
In Indonesia, through U-Report, young girls were able to share
their opinions about child marriage and a delegation of
selected young U-reporters convened a 1-day meeting at the
Ministry of Women’s Empowerment and Child Protection,
which resulted in nine recommendations on child marriage
prevention. A similar process was undertaken in El Salvador
where U-Report was used to bring the opinions of children on
child marriage to the legislative assembly where a prohibitionof child marriage was called for. In Tunisia, U-Report has beenused to gather views from youth on rights to education. In
Liberia, which has the fourth highest participation rate of
U-reporters globally, the government has used the platform toraise awareness around prevention of transactional sex among
school girls (so-called sex for grades). In conflict-affected areasof the Ukraine, U-Report launched the U-ambassadors
peer-to-peer initiative, in which U-Report was used to monitor
water, sanitation, and hygiene; education and humanitarian
programmes; and to provide online counselling on
safe migration.

For more on U-Report see
https://ureport.in

The U-Report initiative could be harnessed as a mechanism forcommunity monitoring of certain Sustainable Development
Goal indicators and the data from polls could be an important
contributor to country monitoring processes.

In Uganda, where the initiative was launched, every memberof parliament has signed up for U-Report and district healthand working with children and youth will the interna­
tional community be able to achieve peace, sec­
urity,
justice, climate resilience, and sustainable develop­ment
for all. Recently, youth activists in the school strike forclimate movement have made forceful arguments tolower the voting age to 16 years, to protect children’s
right to have a say in decisions that affect their future on
the planet.109
Engagement with children can be consultative,
colla­borative, or adolescent led, depending on the specificcontext and purpose. In policy formulation, if the aim isto reach out to as many young people as possible, aconsultative approach might be best, potentially using
digital tools such as U-Report, a free global social media
platform used in more than 50 countries (panel 5).
UNICEF made use of U-Report to gather inputs from
more than 385 000 young people before the Global
Conference on Primary Health Care, held in Astana,
Kazakhstan, Oct 25–26, 2018, to feed into a 1-day
preparatory workshop attended by more than 100 young
participants. However, consultative processes do notalways result in children’s voices being heard: in Uganda,
local authorities only engaged a small number of children
despite the programme being a national child wellbeing

scheme, resulting in a deprioritisation of their needs.110
Among the challenges for effective engagement are
adultism, the notion that adults always know better thanchildren; a reluctance of overburdened local authorities
to take on additional duties of listening to children;
tokenistic child participation; exclusion of the mostmarginalised children; and weak adult facilitators.111,112
Collaborative and adolescent-led approaches have had
powerful positive effects. Adolescent-led initiatives, suchas Greta Thunberg’s school strikes for climate movement
mobilised an estimated 1·5 million students in more than2000 cities worldwide in March, 2019, showing thattraditional models of incorporating children’s voices into
environmental and economic policy have not been suc­cessful, and that social media platforms present catalytic
opportunities to harness young people’s engage­ment. In
2019, there are 1·2 billion adolescents in the world(defined by WHO as persons aged 10–19 years), of whom
nearly 90% live in LMICs.113 Adolescents are better
connected than ever before, attend school more than inprevious generations, and are well placed to drive progresson sustainability.
Adolescents might require adults to provide thescaffolding for engagement, including access to safe

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13

The Lancet Commissions

spaces and a credible audience that they can influence.114
Certainly, investments are required to address social
norms, implement laws, and adopt policies that enable
adolescent rights and create sustainable opportunities
for participation. When these are in place, adolescent-led
initiatives can drive progress on local concerns, such as
the movement of girls in Argentina to claim their sexualand reproductive rights (including the right to abortion);adolescent-led protests concerning road traffic safety in
Bangladesh; the student movement in Chile that led
to a more equitable education system; and the social
movement for better gun control in the USA following
the Parkland, FL, shootings. Equally, grassroots youth
movements can be encouraged to take the initiativeand engage politically in the context of their rights andresponsibilities as citizens.
Worldwide, documentation of children’s own experi­
ences of their day-to-day lives through narratives has
been largely absent from SDG monitoring processes.
Focused, smaller-scale research can provide valuable
insights into the status of children’s wellbeing in diverse
contexts, particularly for younger children. Since 2009,
the Children’s Worlds Study has obtained comparative
multinational data on children’s understanding of well­being. The surveys collected representative data (fromup to 90 000 children from 24 countries) on children’s
lives and daily activities, their time use, and their own
perceptions and evaluations of their wellbeing.117 Resultsfrom the second survey wave found that children felt
most satisfied with their family life and friends, lesssatisfied with their local environment and life as a
student, with the lowest amounts of satisfaction relating
to their own future, especially in LMICs, such as Ethiopia,
Nepal, and South Africa.
Innovative methods to understand children’s percep­
tions of their environments include crowd-sourcing via
social media, photovoice, and community mapping. They
can garner children’s views on the policies that affectthem and integrate their views into explicit policy andmonitoring frameworks. For example, a study fromSouth Africa found that children from poorer commu­
nities were more constricted in their mobility and unable
to access safe natural spaces compared with children
from wealthier communities. The authors recommended
that town planning processes include children as key
contributors using participatory frameworks, such as
UNESCO’s Growing up in Cities model.116 Anotherpromising model of a participatory system for child rights
accountability internationally is Global Child Rights
Dialogue, an international consultation project that aims
to seek children’s input on the attribution of their rights
as articulated under the CRC, in 40 countries aroundthe world.117

Families’ rights and responsibilities in nurturing their children
The realisation of children’s entitlements depends onfamilies. Young children require a stable environment
14

created by parents and other caregivers to ensure good
health and nutrition, protection from threats, opportu­
nities for early learning, and love and emotional support.
Beginning with the maternal-infant dyad, the child’s
biological and developmental trajectory is ideally set in
the context of nurturing relationships. The rights,
freedoms, and entitlements of children can only be
advanced when the entitlements of their mothers andcare givers are realised. Moves to promote genderequality will improve nurturing care in the early yearsof life. A study covering 116 LMICs from 1970 to 2012
explored the relationship between two readily available
proxies of women’s control over their lives: the numberof girls enrolled in secondary education and the ratio of
female to male life expectancy.118 Improvement in these
two indicators was associated with 32% of the decline instunting, a common proxy for child development, overthe 42 year period for these countries. Within this broader
understanding of the place of families in raising children,
we consider the diversity of families and their changing
social con­texts, before considering key power relations,barriers, and enablers that families face in raisingchildren in the SDG era.
Considerable diversity exists in family composition.
A child could live with a single parent, two married or
cohabiting parents (of any sex or gender), a grandparent,
foster family, adoptive parent, or another relative or
guardian. A child might live with siblings in a nuclear,joint, polygamous, extended, or blended household
whose members are at home or elsewhere. Some child­
ren are orphaned and do not live with their biologicalparents. In 2018, worldwide, there were 140 million
orphans (defined as any person under the age of 18 years
who has lost one or both of their parents due to deathfrom any cause).119 Double orphans have lost both parents
and make up 15·1 million of those children. Orphans
often lack the protective buffer that familial structuresideally provide. Other children might live with disabledparents or caregivers, or be disabled themselves, and do
not have access to expert and peer support for families
and caregivers, to which they are entitled. According todata from the Social Trends Institute’s World Family
Map, children in sub-Saharan Africa, the Americas, andwestern Europe are less likely to live with both parents
than children in Asia, the Middle East, Oceania, andeastern Europe (figure 4).120 With the exception of the
Middle East, the proportion of births occurring outside
marriage varies widely. Children around the world not
infrequently become parents themselves, with 16 million
girls aged 15–19 years and 2·5 million girls younger than
16 years old giving birth each year in LMICs.121
In addition to regional differences, family structures arechanging, linked as they are with demographic trends,
and influenced by social, political, and environmental
variation. Worldwide, life expectancy and the age at which
women have their first child are rising, and fertility rates
are falling. Economic migration and urbanisation disrupt

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The Lancet Commissions

traditional family structures, whether these are nuclear
families in some contexts or extended families in othersettings. Economic opportunities often take parents awayfrom their children, even when their decision to leave ismotivated by a desire to advance their children’s welfare
and opportunities, complicating understandings of family
wellbeing. As industrialisation and urbanisation accelerate
in many parts of the world, hundreds of millions ofchildren are left behind by their parents seeking work, andthey face increased risk of mental health problems andpoor nutrition, with no evidence of any health benefit.122
In HICs, the already substantial proportion of singleparent families is expected to continue to rise, to up to
27-40% of households in the USA, Australia, Austria,
Japan, and New Zealand by 2025–30.123 Women who are
divorced or separated and single-parent families are
more likely to live in poverty, which has implications
for the social determinants of health. Furthermore, in
sub-Saharan Africa and central and South Americafamilies are more likely to have a head of householdwithout secondary education compared with other partsof the world, and in sub-Saharan Africa the head ofhousehold is less likely to be employed (figure 4).
Meeting basic needs remains a challenge for manyfamilies living in deleterious social, political, and eco­nomic conditions. Many families are unable to ensure
their children breathe clean air or have sufficient goodquality food and water, or live in a sanitary environment.
Despite these odds, many are still able to meet theirchildren’s needs for love, belonging, respect, confidence,and self-esteem. Recognising such resilience and theability of families to support and realise their child­ren’s rights and entitlements must also be matchedby government policies to address challenges posed bysociopolitical, economic, and environmental threats.
Thus policy change remains a powerful way of shaping
a progressive society that supports healthy growth,development, and equality. For example, improving girls’
completion of quality schooling, safe transportation
options for girls and women, productive labour force
participation by women, and paternity leave policies formen creates enabling environments for a more genderequitable society.124
Families can also be the locus of violence in a child’slife, in part because of structural issues, such as dis­
crimination and poverty, with consequences across thelifespan of the child and for society. This is particularly
the case for girls and young women, as well as children
who have non-conforming gender identities and sexual
orientations. More than 1 billion children—half of allchildren—are exposed to violence every year,125 including
about six in ten children world­wide who are subjected toviolent discipline by their caregivers on a regular basis.126
The enduring effect of violence against children is wellknown, including increases in the risk of injury, mental
health problems, sexually transmitted infections andreproductive health problems, and non-communicablediseases—including cardiovascular disease, cancer,
chronic lung disease, and diabetes.127
Violence against children also begets further violence:high proportions of incarcerated people experienced
violence as victims before becoming perpetrators, repre­
senting costs to society as well as to children themselves.
A cross-sectional study of more than 36 000 US men
and women suggested that nearly half of antisocial
behaviours in adults could be accounted for by harsh
physical punishment or maltreatment when they werechildren.128 Society has a responsibility to protect children
from violence within families, but worldwide govern­
ment intervention into intimate family situations forchild maltreatment falls heaviest on marginalised popu­
lations, including indigenous families, and racial andsexual minorities. Further, domestic violence is moreconcentrated in communities that experience poverty andstreet violence and have poor access to services, yet theharm done to children by family separation, particularly
for indigenous and minority populations, must also be
understood as a type of structural violence. But theconverse is also true: a poorly functioning social welfare
and justice system regularly fails children who need to be
removed from parents who abuse them, a fact rarely
explicitly acknowledged by policy makers.

It takes a village: the community’s role
The empirical evidence on the role of community engage­
ment in improving health outcomes for children andfamilies is compelling, although the concept is not yet
fully theorised.129,130 Definitions of community are basedon people’s sense of belonging together, and the idea ofcommunitas—inspired fellowship—which refers toshared experience and togetherness strengthened by ritesof passage. However, all communities have hurdles tobelonging, and the management of rights and res­pons­
ibilities is an ongoing project. Communities can include
and exclude, or have different forms of political mean­ing
internally and externally.131 Rather than thinking ofcommunities as empty spaces in which policy and pro­grammes paternalistically mould families into modern
behaviour, nominally consult traditional authorities, or
enable time-bound, project-defined com­munity activities,
an expanded vision of communities recognises their own
active role and layered power relations that influencechild health and wellbeing.
Community stakeholders span public and private
services, formal and informal associations, traditionaland modern worlds and, at times, syncretically crossthese boundaries. Community groups can improve childhealth and wellbeing by sharing information, supporting
each other, and building capacity among local stake­holders; advocating for external resources from districtauthorities; and building the confidence of people inpoverty to ask why their entitlements are not being met. A
large amount of literature supports the value of self-helpgroups and participatory learning and action groups in

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15

The Lancet Commissions

A

Asia

Malaysia and Japan

North America

USA

CanadaMiddle East

Egypt, Israel, and Jordan

Oceania

New Zealand

Sub-Saharan Africa

South Africa

Nigeria

EuropeUK

Central and South America

B

10

20

30

80

Qatar

Oceania

Australia

Egypt
New Zealand

Democratic Republicof the CongoSouth Africa

EuropeItaly and Spain

Central and South America

FranceBrazil and Costa Rica

0

Asia

0·5

1·0

Bolivia

1·5

2·0

2·5

3·0
3·5
Total fertility rate

India
Canada4·5

5·0

Oceania

New Zealand

Ethiopia

UgandaPolandCentral and South America

FranceArgentina

10

Asia

Colombia

20

30
40
50
Proportion of births outside of marriage (%)

60

70

Japan
USA

Middle East

TurkeyCanadaIsraelOceania

Australia
Tanzania

Nigeria

EuropeSpainCentral and South America

16

80

Malaysia

North America

Nicaragua

0

E

6·0

USA

Australia

EuropeFigure 4: Family
characteristics in a sample of
60 high, middle, andlow-income countries:
proportion of children living
in a household withtwo parents (A); total
fertility rate (B); proportionof births outside
marriage (C); proportionof children living witha household head who has asecondary education (D);proportion of children livingwith a household head who
is employed (E)5·5IsraelTurkeySub-Saharan Africa

4·0Philippines

North America
Middle East

100

USA

Sub-Saharan Africa

Sub-Saharan Africa

90

Philippines
CanadaMiddle East

D

Peru

40
50
60
70
Proportion of children living with two parents (%)

South Korea

Asia
North America

C

PolandColombia

0

TurkeyAustralia

10

Poland

Chile

20
30
40
50
60
70
80
Proportion of children younger than 18 years with a household head with a secondary education (%)

Asia

90

100

Japan

North America

USA

Middle East

JordanOceania

CanadaEgypt
Australia

Sub-Saharan Africa

South Africa

Nigeria

EuropeIrelandCentral and South America

Nicaragua010Poland

Chile

20
30
40
50
60
70
80
Proportion of children younger than 18 years with a household head that is employed (%)

90

100

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The Lancet Commissions

improving maternal, newborn, and child health. Analysesof national data in India showed respondents fromvillages with a self-help group had 19% higher odds ofmothers delivering in an institution, 8% higher odds of anincrease in colostrum feeding, and 19% higher odds ofusing family planning products and services.132 Largescale cluster trials of community participatory learningand action women’s groups in Nepal, Bangladesh, India,
and Malawi reported a 30% reduction in newborn
mortality, with substantial changes in preventive behav­
iours among attendants at birth.133 WHO formally recom­
mended the participatory learning and action approach,particularly for rural populations where new­born mort­ality is high.134 Sub­sequent studies of the participa­
tory
learning and action approach using some of the 1 million
accredited social health activists in India showed a
31% reduction in newborn mortality, as effective as theproof-of-principle studies.135 These effects in eastern India
were replicable and sustained.
Effects of community-level interventions on childnutritional status, and on determinants thereof (such as
water, sanitation, and hygiene), have been more difficult
to achieve. A Cochrane review to evaluate the effect ofinterventions to improve water quality and supply suffi­
cient to maintain hygiene practices, provide adequate
sanitation, and promote handwashing with soap, on the
nutritional status of children, concluded that very few
studies provided information on intervention adherence,
attrition, and costs.136 In 2014, a trial of India’s total
sanitation campaign (which aims to change social norms
and behaviours, with technical support and financial
subsidies) showed only modest changes in the uptake ofhousehold latrines and in reducing the amount of openair defecation.137 A review of the literature reported thatwater, sanitation, and hygiene campaigns reporting aneffect on child diarrhoea and linear growth achieved highadherence via frequent household visits.138 Nonethelessas improved water and sanitation can improve children’s
health and wellbeing through other mechanisms, suchas reducing time obtaining and transporting water andimproving girls’ school attend­ance after they begin men­struating, it should be delivered as a government-fundedintervention, with the collaboration of communities.
Community engagement can be more challenging in
informal, urban settlements than in more stable, ruralcommunities. Services and resources are managed byplace; however, more agile systems are required to maintainresponsiveness to changing needs given the fluid nature ofurban migration and unregulated settle­ment. Informality
poses specific challenges, including the challenge of accessto health resources in urban areas.139 Yet, a large study
in the slums of Mumbai, India, suggests that solutions
exist: local resource centres delivering integrated activities
to improve women’s and children’s health in informal
urban settlements increased met need for family planning(by 31% in interven­tion clusters compared with control
clusters) and child immunisation rates.140

Community health workers are widely seen as apractical path to reach child health goals, particularly
in rural and low-income settings. A review of theeffectiveness of unpaid, non-professional volunteers andpaid, professional health workers in malaria prevention,
health education, breastfeeding promotion, essential
newborn care, and psychosocial support showed benefitsof varying degree in all categories.141 Children’s early
development can also benefit from community healthworkers. In Pakistan, children who received responsive
stimulation in a trial of female health worker home
visits had statistically and clinically significantly higher
development scores on the cognitive, language, andmotor scales than those who did not.142 In California,
USA, a randomised clinical trial of the provision of inperson help to navigate relevant community services
statistically and clinically significantly decreased reportsof social needs by families and improved children’s
overall health status compared with controls.143
However, evidence suggests a high attenuation of these
positive effects when governments take proof-of-principle
community health worker studies and implement themon a larger scale, and more research is needed on per­formance and quality of care provided.144 Two systematic
reviews considered interven­tions on how to improve theperformance of community health workers.145,146 Imple­
mentation factors, such as recruitment, supportive super­
vision, incentives, commu­nity embeddedness (whereby
community members have a sense of ownership of
the programme and positive relationships with the com­munity health workers), continuous education, andadequate logistical support and supplies are crucial for
success. For example, in South Africa, a trial of improved
training, continuous quality improvement, and mentoringof community health workers, increased the number ofmothers breast­feeding their children, the number andquality of visits made to mothers, and the knowledge of
mothers.147 But too often governments and practitioners
do not assess the relevance and feasibility of thesestrategies before implementation of community healthworker pro­grammes. Too little attention is paid to healthsystem decentralisation, social accountability, and gov­
ernance. Simply training more and more community
health workers, without adequate support, is unlikely tobring benefit.
Power relations are a core part of how communities areconstituted and reconstituted over time, including how
social boundaries and norms are shaped and enforced.
Unequal or oppressive power relations exist not only
between marginalised communities and overarching
structures (such as governments), but also within com­munities. For example, sexual-minority youth are at twoto three times higher risk of suicide compared with theirpeers, a fact linked to non-accepting social environments
and poor emotional and social support.148 However, someevidence suggests that focused interventions can lead topositive outcomes. Community dialogues around issues,

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17

The Lancet Commissions

such as caste discrimination and female circum­cision,require delicate negotiations around social identity anddirect challenges to illegitimate uses of power, but havebeen shown to facilitate changes to social norms when
done sensitively.149
Some observers have expressed scepticism thatparticipation leads to empowerment or to lasting andmeaningful social change. They see poor engagement as aresult of underlying power dynamics, and an undueemphasis on voluntarism as a failure to tackle the difficult
politics of disempowering elites through specific proequality approaches.150 Whereas, others believe thatparticipation can lead to truly transformative outcomesin development, provided the approach taken is poli­­tical, rather than technocratic.151 Social movements canbroker political alliances to transform the lives of many,
examples of which include the anti-dam movement inIndia; the shift in control from economic elites to politicalparties in Kerala, India; participatory budgeting in Brazil;
and the control of forests by local users in Nepal.152 Larger
social movements have a role to play in demanding therights that communities need to care for children andprovide for families.

Government as a project of shared responsibility tochildren
Safeguarding the health and wellbeing of children, likethe health of our planet and environment, requires
concerted public action. Governments are the natural
locus of our shared responsibility for these matters, assuch they have a central role in financing services forchildren, ensuring the effective delivery of services, andproviding adequate social protection for families. Specificgovernance arrangements at national and subnational
levels are further developed later in the Commission,
wherein we explore issues of multisectoral collabora­tion and links between different local, regional, andnational governments.
In countries of every income, governments have acentral role in the public financing of services forchildren. Only public financing (tax financing or social
insurance) can ensure equitable access and provide
financial protection against the cost of using services.
Experiences from HICs show that different models ofservice provision for children and families can work,from predominantly public to mostly private, as long as
public financing has a central role. In these countries,
delivering children’s entitlements—security, health care,immunisation, water and sanitation, education, andsocial protection—is a responsibility primarily for the
public sector, which can alternatively contract out toprivate or non-governmental partners under government
supervision.
In LMICs concerns exist that some governments faceenormous challenges in delivering even the most basic
services, and some evidence suggests that non-state
actors can provide these services more effectively in18some cases. For example, trials in Kenya and Liberia haveshown in head-to-head comparisons that the same
programmes are less effective when put in the hands ofgovernment compared with private providers.153,154 A
meta-analysis of trials evaluating a wide range of health,education and social assistance interventions findsthat those implemented by government are on averageless effective than non-state providers.155 These studies
typically focus on not-for-profit organisations and lessevidence exists for the value of contracting for-profit
providers, whose involvement remains controversial.156
However, in many LICs, government must retain the
primary role for service provision for two reasons: first,
only the government in these settings has the capacityand mandate to reach a large proportion of the population;and second, the ability of the national government islikely to be too weak to manage and monitor numerous
complex contracts with private providers. These factors
gives rise to the question: how can countries improvethe effectiveness of their government bureaucracy?
This question is government-wide, not about any one
sector; therefore, it has resonance for delivering services
to improve child health and wellbeing, which span
multiple sectors.
Countries can improve the effectiveness of the govern­
ment bureaucracy to provide the over-arching services
children are entitled to by focusing on better management
practices, particularly for middle-tier bureaucrats. Frontline public sector workers or so-called street level bureau­crats157 have been the focus of many studies, which havetested ideas focusing on the selection and recruit­mentof public officials,158 pay for performance,159 prosocial
motivation,160 and career concerns.161 However, the role ofmiddle tier bureaucrats—those who sit between seniorcivil servants and front-line workers, responsible fortransforming political preferences into policy and imple­
mentation—is often under-appreciated. In-depth studies
in Nigeria162 and Ghana163 show that management practices
are critical determinants of bureaucratic performance.
Practices related to autonomy are positively associatedwith better public service delivery, but practices related toincentives and monitoring of bureaucrats are negatively
associated with performance, suggesting that countries
with low levels of state capability might benefit fromproviding public servants with more autonomy. Further
work in this area emphasises the important role ofmanagement at the district level,164,165 which is a key
governmental tier for delivering child health services.164
In all cases, governments play an irreplaceable role inreaching the poorest and protecting the most vulnerable
members of the population, and social protection forchildren and families is a key responsibility. According
to the Social Protection Floor Initiative,166 every person
is entitled over their lifespan to basic health care andbasic income security as part of a comprehensive social
protection package. However, more than one in threepeople, and more than half in rural areas, worldwide dowww.thelancet.com Published online February 18, 2020 https://doi.org/10.1016/S0140-6736(19)32540-1

The Lancet Commissions

Health, education, infrastructure,
biodiversity conservation andclimate adaptation, and social
protection*
Health Sustainable Development
Goals‡

Low income

174

195

Other low income†491

Low income

50

Lower-middle income

62
135

11

Upper-middle income
Education§

533

Low income 26
Lower-middle income

Financing projection (US$)

3

45
138

8

Upper-middle income

402
0

Total cost projection

187

100

200

6
300

400

500

600

700

2014 US$ per capita
Financing gap

Figure 5: Estimated costs & financing gaps for the Sustainable Development Goals*59 countries, 2018–30, US$2014 per capita. †Other low-income countries have a per capita income of between $996 and $2700. ‡Coverage expanded for close to
200 interventions recommended by WHO to advance the health Sustainable Development Goals, with associated costs for health system strengthening (67 countries,
2016–30, $2014 per capita); not all countries had a funding gap, if the subset of lower-middle income and upper-middle income countries with a financing gap were
examined the gap would be $51 per capita for the lower-middle income countries and $66 for the upper-middle income countries. §Preprimary, primary, andsecondary education (2015–30, $2014 per capita). For the methodology and sources see the appendix pp 3–4.

not have health protection by legislation, affiliation, or
health insurance—although this is affordable in all
countries.167,168 In western and central Europe health care
protection coverage is almost universal; whereas, in Asiaand the Pacific 40% of the population and 70% of the
population in Africa are without health-care protec­
tion, despite several studies showing protection afford­
ability.168,169 For families providing support to a disabledchild the costs of health care might be prohibitive andplace a huge burden on them. Many countries need totake further steps to develop strategies to harness existing
resources, with analysis of the relationship between typeof risk and health care protection financing.
Social protection measures (including social healthinsurance and tax financed health care), like all public
expenditures, can be more or less equitable. According
to the latest evidence from the World Bank ASPIRE
database on the distribution of social protection spending,
the richest fifth of the population takes up about three tofour times more social insurance resources than thepoorest fifth in the average country. Health insurance andsocial protection are important instruments to ensure
universality and equitable access to health-care services
by children and their families. The difference between
urban and rural health-care coverage attests to thedifficulties in relying on the community or other small
scale ways of pooling resources and sharing risk. A
universal approach, primarily funded through general(progressive) taxation (and with development assistancein the poorest countries), is the best option to financehealth-care coverage for the entire population, inparticular those who cannot contribute, such as informal
workers or women excluded from the productive sectors.

Financing governments’ efforts for children and the SDGs
To achieve the SDGs and deliver the entitlements
previously outlined, many countries will need to invest in
the scale-up of high-quality services across sectors.
Several studies have investigated the cost of this scale-up
through so-called SDG price tags and compared thesecosts with projections of financing likely to be available
under different scenarios. Such analyses are not childspecific and are inherently uncertain, but they do give asense of the order of magnitude (figure 5). In the healthsector, the cost of scaling up priority interventions andstrengthening the health system to meet the SDGs by2030 is estimated to be on average $112 per person in
LICs and $146 per person in lower-middle income
countries.170 Projections suggest that some countries will
not be able to finance these costs, generating a financing
gap of $62 per person in LICs and $11 per person inlower-middle income countries (appendix pp 3–4).
Equivalent figures are available for education.60 In 2018,
an analysis of all the SDGs that combine sector
specific costs reported a substantial financing gap of$195 per person (figure reported according to the valueof US$ in 2014 for comparison across studies).171 These
global estimates are preliminary, and more precise
estimates will require country specific analyses based on
local data.
Mobilising more public financing from domestic
resources will be key to providing predictable andsustainable funding to achieve the SDGs. As trends inhealth and education over the past few years show,countries rely increasingly on government spending fromdomestic resources and less on development assistance.60,172
To mobilise more domestic spending, countries will

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19

The Lancet Commissions

Getting governance right for children

Panel 6: Getting governance right for children—key messages• National governments are the lynchpin of efforts to deliver children’s entitlements• A powerful new framing of children at the centre of the Sustainable Development
Goals can help build national political priority and raise domestic financing• Deliberate design choices are required to ensure different sectors act jointly forchildren• Local governments link national governments to families and communities, but
require support, finance, and devolved power• Fragmented global governance could be ameliorated by a powerful new framing
around child rights and the Sustainable Development Goals

need to maintain economic growth, improve their taxa­
tion capacity, and prioritise the SDGs in national andsubnational budgets. If countries increase taxes itshould be done in a progressive manner. Countries should
explore the wide range of options for domestic financing(discussed in further detail later). Considerable scope also
exists to improve efficiency (eg, 20–40% of worldwide
health expenditure is estimated to be wasted) by reducing
waste, tackling corruption, and allocating government
spending towards effective interventions both within andbetween sectors.173
Development assistance will continue to be a vital
source of funding in the poorest countries. If bilateral
donors were to increase spending to the 0·7 percent of
GDP benchmark (adopted by the UN General Assemblyin 1970 and repeatedly re-endorsed), this would increaseinternational aid substantially. There is great potential toredirect and target existing aid to SDG-related activities in
LICs, and away from middle-income countries (MICs),
which currently receive a sizeable amount of aid in
absolute terms (often earmarked for specific diseases orprogrammes). Beyond traditional channels, a range ofother financing ideas have been proposed.171 They include
improving tax administration by addressing tax evasion
strategies, such as profit-shifting by large multinational
companies, and implementing a range of new taxes, suchas a global carbon tax with the proceeds directed to theSDGs, a financial transaction tax, offshore accounts tax,
high net-worth individual tax, and a tech tax on the natural
monopolies emerging in the tech industry. Blended
financing instruments, such as the Global Financing
Facility, The Vaccine Alliance, and the Global Fund also
hold promise in using development financing to leverage
additional domestic and commercial resources towards
the SDGs.

Summary
Here, we have laid out a set of entitlements for children.
We examined how children themselves can participate
in reclaiming their rights, and the responsibilities offamilies, communities and governments in ensuringthem. Next, we take a detailed look at how multisectoral
governance arrangements can be reshaped to deliverchildren’s entitlements now and in the future.
20

The task of achieving the SDGs should galvanise
governments to deliver the rights and entitlements ofchildren and young people, but child advocates andgovernments must generate the political priority andbuild fiscal and administrative capacities to do so. In the
SDG era three leadership and governance challenges
stand out: first, how to move interest in child healthbeyond the health sector to develop holistic, integrated
national policies for children, with augmented govern­
mental capacity to carry them out; second, how toempower subnational and local governments to takemultisectoral action; and third, how to reform andintegrate the global governance architecture and develop
new global agreements pertaining to children to support
such multisectoral action (panel 6).

National governance: how to make children a priority,
mobilise funds, and organise action
National governments are the lynchpin of efforts todeliver child entitlements: realising the rights of children
to health and wellbeing depends on the leadershipand commitment of governments, aligned institutional
incentives and accountability across sectors, increased
financing, and robust legislation.

Building political priority and mobilising domestic resources
For national governments, child wellbeing is rarely an
explicit concern for top political leaders (eg, heads of stateand prime ministers), and usually is handled by specificgovernment departments (eg, social welfare, health,education, or youth) that might not possess the politicalleverage required to work across sectors to achieve theiraims. A handful of countries have developed over-archingpolicies backed by national programmes dedicated to child
wellbeing, including Ireland, New Zealand, Uganda, andthe UK, but policies in most countries are not cohesive anddo not have sufficient political force, including those withnational Children’s Commissioners. Many programmes
are under resourced. Moreover, attention given to various
dimensions of child wellbeing is patchy, with some areas(such as child survival) receiving substantial resources andothers (eg, protection against environmental pollu­tion andviolence) considerably less.174
Stakeholders must be deliberate about building
political priority and mobilising domestic resources forchildren. Policy reform explicitly decides who receives
valued goods in society, but power dynamics are under­
appreciated in policy processes of health and other social
sectors.175 Emerging literature on how to build nationwide political prioritisation for health issues provides
some lessons. Specific policies can be advanced directly,
when political authorities focus attention on issues,harness finan­cial res­ources, control regulatory regimes
and pressure policy actors, or indirectly, when they create
institutional incentives and set up trade-offs with otherpriorities.176–179 Case studies of successful advocacy efforts

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The Lancet Commissions

Higher

Sector-specific taxes(on corporations)

VAT with a shareearmarked forchildren’s healthand wellbeing
Fundraising potential

suggest that strategies for positive change, althoughcontext-specific, pay heed to leaders’ need to maintain
political legitimacy (in whatever form),177 as well as theformation of healthy coalitions that can support and pro­pel policy ideas. Advocates for children have the advant­age of possessing a winning argument from multiple
standpoints: affective, ethical, economic, and fin­ancial.
Advocacy and coalition-building efforts for children canbenefit from the built-in infrastructure of countries’
efforts towards the SDGs, newly recon­ceptualised aroundthe figure of the child, as previously argued in thisCommission.
Political prioritisation is a prerequisite of and anaccompaniment to mobilising domestic resources in all
countries—for all sectors that contribute to child healthand wellbeing. LMICs fund most of their social sectors
through domestic resources, with a few exceptions, andthis reliance on domestic resources will only increase as
official development aid continues to recede in impor­tancefor most countries’ economies. Development assis­tance
now accounts for less than 1% of all health spending, andprojections suggest it will reduce further,180,181 although fora handful of countries it remains an important, albeit
volatile, source of financing (in many countries it still
remains important for funding of activities for margin­
alised populations).
Given these trends, most governments will require
even greater domestic financing to meet the investment
needs of children.182 As noted by the WHO Commission
on the Social Determinants of Health183 a decade ago,rich countries essentially choose their amount of childpoverty through the redistribution policies they enact.
In many emerging economies there is fiscal space toboost spending on children, across all sectors. Repri­
oritising spending towards the needs of children andimproving efficiencies in the use of funds is possible inall countries, and doing so opens the opportunity to
improve equity, as governments have the ability to pool
resources and ensure financial protection for house­holds. Enormous variation exists across countries
regarding the extent to which governments prioritise
health, education, and other social sectors within theirbudgets. Historical data can be useful in providing abenchmark for what might be feasible. For example, if
the government of India were to spend 5% of GDP on
health, matching the percentage spent by many LMICs,
this would increase domestic government healthspending by four times.184
In addition to reallocating existing funds, countries canalso seek to increase the total amount of funds available.
Governments can increase tax revenue through smart
policies and administrative reform, to raise funds forchildren in the general budget (figure 6).185,186 So-called
health taxes, such as those on sugar, tobacco, and alcohol,
are not only important for reducing consumption of
unhealthy substances, but they can help generate
revenue for health. However, mobilising a fair tax system

Levy on currencytransactions

Carbon tax
Tobacco excise taxes

Financialtransaction tax

Diaspora bonds*
Levies on mobile phone use

Excise taxes on alcohol,
sugar, and unhealthy foods
Luxury taxes
Tourism andtravel-related
leviesLesserSelling franchised products
General philanthropy

Regressive

Pro-poor
Regressivity

Figure 6: Domestic financing initiatives available to policy makers
VAT=valued added tax. *Diaspora bonds are financial instruments issued by countries targeting expatriates living
in wealthy countries; diaspora members purchase bonds issued by the government despite lower interest rates andreturns, typically for patriotic reasons. Such a system has been successfully implemented in Israel.

is much more important: one which uses all modalities,
especially genuinely progressive income taxes, with ashift from income towards carbon taxes, and broad-basedcon­sumption taxes, which are regressive and need
explicit balancing of their potential negative effects on
income and wealth equity. Revenues should be sharedacross sectors contributing to improving child health andwellbeing, and the share of the budget devoted to children
should be monitored by the national govern­ment andcompared internationally.
The extent to which a country can tap into each ofthese channels will vary on a case-by-case basis;
however, what is common across countries is thecentral role that the ministry of finance will play ifdomestic resources are to be mobilised for the SDGs,
echoing the need for the prioritisation of child healthand wellbeing by senior government members. Those
advocating with finance ministers for more investment
in children need to forcefully make the case thatsuch spending is not only good for their wellbeing, butalso for productivity and the economy. Advocatesmust engage with the national budgeting process andcommunicate using language that is understood byfinance ministers.
Many economists, including Nobel prize winners
Joseph Stiglitz and Paul Krugman, have described theharm done by neoliberal austerity policies. Clear evidenceshows that austerity cuts welfare benefits, increases
inequality, and harms the poorest families the most.
The proponents of austerity say it is necessary to cut
national debt. Yet these policies often actually increase
the national debt burden—in the UK the national debt
increased by £860 billion from 75% to 85% of GDP
between 2010 and 2018. So, in arguing for investment forchildren, advocates should contest the arguments put

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21

The Lancet Commissions

Panel 7: Case study of multisectoral partnerships: Chile Crece Contigo
Chile Crece Contigo, or Chile Grows With You, is a programme to help all children reach
their full potential by providing coordinated services across public sectors, from theprenatal period to 4 years of age. The programme was introduced by then President
Michelle Bachelet, a paediatrician by training, adopted by law in 2009, and implemented
nationwide, financed by a permanent line in the national budget.
According to a case study by Milman and colleagues,198 Chile Crece Contigo was found to
be cost-effective and associated with a decrease in the proportion of children younger
than 5 years old with a developmental delay, from 14% to 10% over the 10 years of its
implementation. Nearly three-quarters of beneficiaries described the programme as being
central to their experience of pregnancy and parenting, suggesting high satisfaction with
its services.
The success of Chile Crece Contigo is predicated on a sophisticated design for multisectoralcollaboration. First, the programme’s introduction, in addition to being backed by seniorpolitical leadership, was characterised by deliberate consensus-building by a broad swathe oftechnical and political stakeholders at national and regional levels. Such early consultation
led to buy-in and investment by all sectors. The programme is housed in the Ministry ofSocial Development, selected for its longer experience of coordination between sectors atnational, regional, and communal levels, compared with the ministries of health andeducation, which are nonetheless highly involved in delivering services. Implementation of
the programme builds on existing systems within all three ministries and pre-existing
municipal networks for community-driven programming. Financing is centralised throughthe Ministry of Social Development, with transfer agreements for funds specifying technicalstandards for the government to monitor and manage quality of services.
Feedback loops for monitoring and evaluation, including periodic reviews, have identified
some areas for systems strengthening, such as around fund transfers to institutions andintegration with other government data systems. Ideally, these feedback loops will allow
continued improvement in the Chile Crece Contigo programme and provide a basis for
multisectoral collaboration that is broadly applicable to child health and wellbeing
programmes in other countries.

forward for austerity policies being necessary for national
debt reduction.
Finally, so-called child-friendly budgeting has been usedin some countries to quantify total public spending onchildren and adolescents, including both direct expenses(such as for vaccination and primary education) andindirect expenses (including food support or cashtransfers to families). In a review of 14 country expe­
riences, ministries of finance and planning usually
oversaw the process and involved stakeholders fromdiverse sectors.187 In Mexico and Peru, measurement
exercises were conducted during the preparation phase of
the budget cycle, allowing for planned expenditures onchildren to theoretically influence budget decision
making. Child-related expenditures did rise, although nodirect evidence suggests that child-friendly budgeting
processes were the cause of this increase. However, inall surveyed countries, the findings of measurement
processes were publicly released, providing improved
transparency of child-focused spending. Further researchis required to determine whether child-friendly budgetingcan be an effective tool to improve domestic resource
mobilisation for child health and wellbeing.
22

Take deliberate action to coordinate and share responsibility forchildren across sectors
As previously discussed, all sectors have a role to play inpromoting children’s health and wellbeing, and theevidence is clear on the need for multisectoral action forchildren.188 However, ministries responsible for different
aspects of child wellbeing rarely coordinate well.189,190
Several factors perpetuate this problem. One is national
financing arrangements, which are siloed by minis­
tries,191–193 a problem compounded by poor impetus for
multisectoral coordination in national cabinets. Inter­
ministerial politics, competition for annual budgets, andinterpersonal rivalries are further obstacles.194 Insufficientcountry experience and capacity for planning policies
across sectors is common, and stronger mechanisms areneeded to help sectors coordinate.195 Finally, even whenpolicies are coherent, they are rarely backed by costed andfunded implementation plans.189,196
The SDGs provide an opportunity to address thesechallenges head-on. Although the evidence for whatworks is not yet robust,199 some key strategies are available
to support improved multisectoral governance andexecute the political push to move forward on a childcentred SDG agenda. Specifically, executive pressuremust bring the sectors together; make clear roles andresponsibilities for each sector, with clear accountabilities
and indicators; ensure financing from a coordinating
source to be used as incentive and facilitator; and use
cross-cutting ministries (such as ministries of finance,planning, or social welfare) to validate, coordinate, andshare data. In Chile, executive leadership and cabinet
buy-in were essential to drive coordination across sectors,
with the strong involvement of cross-cutting ministries.
Chile’s multisectoral programme for improving earlychildhood development (Chile Crece Contigo; panel 7)
provides a model for defining roles and budgets acrosssectors, and financing and monitoring systems thatencourage collaboration.54,198
Policies across sectors must be examined for theirpotential effect on child health and wellbeing. The content
of these assessments could draw from the child enti­
tlements framework, discussed earlier, and by reviewing
existing guidance from UNICEF and the World Bank,199
on integrating a child focus into poverty and social impact
analysis, and from the work of national governments,
such as New Zealand, which has introduced a budgeting
approach in which cost-benefit analyses are based on
current and future wellbeing. The Health in All Policies
discourse also provides technical tools and resources.200
These efforts should be flexible, ideally using mechanisms
within each country government’s own structures, andlinked to existing country reviews taking place under the
auspices of the CRC.
Success is predicated on the basis of a sophisticatedunderstanding of the key actors, their incentives andconstraints, and the functioning of the overall politicalecosystem, with distributed leadership that engages a

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The Lancet Commissions

broad coalition of stakeholders.201 Tools for political
economy and power analysis are available to map key
actors and institutions and understand their potential
interactions, but are under used. Such analyses, along witha sophisticated framing of child wellbeing that appeals toall, can be supported by global agencies, but must be led bycountry institutions as part of their political prioritisationand multisectoral action. The over-arching goal must be
sharing the responsibility of child health and wellbeing
beyond the health sector, and instituting mechanisms ofgovernance, financing, and account­ability to do so. Specificattention should be paid to changing the lens of the healthsector itself to recognise the contributions of other sectors
and work with them as equal partners. The pitfall of socalled health imperialism (in which stakeholders in thehealth sector assume that health interests predominate)
can alienate other govern­ment departments that, under­
standably, hold different priorities.202

Empowering local government in municipalities anddistricts
As intermediaries between national governments andcommunities, local and municipal governments hold an
essential responsibility in the improvement of child andyouth wellbeing. However, local and municipal govern­­ments face a number of challenges and their capacity toeffect change is often small. Strong local govern­­ments,
with deliberate multisectoral governance models, cantranslate children’s entitlements from national govern­ments to families and communities.

Strong local governments link households and communities tonational initiatives
Ideally, local governments address the local social
determinants of health, implement public health policies
and programmes for children and young people, andcoordinate multisectoral action for the children mostaffected.203 District and municipal authorities are often
focal points in convening and coordinating the actionsof multiple actors. The capacity of local government tomanage relationships, improve synergies, constructively
resolve conflict, and mobilise populations, is an essential
role in the SDG era.
However, a review of child policies from countries asdiverse as Moldova, Malawi, Jordan, and Cambodia re­vealed several common challenges.190 Vertical coordination
between national and subnational governments createdchallenges in balancing divergent priorities, revision ofpolicies that did not account for local context, managementof overly-centralised or overly-decentralised coordination
mechanisms, and tension between national and local
control over budget management often in the face of
weak local capacity. Local governments are often caught
between the competing priorities of governments, donors,
and implementation partners, and sometimes the local
interests of powerful extractive, agricultural, service, ormanufacturing industries. Particularly in donor-dependent

countries, poor local government capacity has prompted
authorities to turn to international and local non-govern­
ment organisations to assist with provision of services.204
Local authorities’ ability to act depends on politicalcircumstances, the status of decen­tralisation, and, mostof all, budgetary power, coupled with the extent towhich the national govern­ment supports the activities of
local governments. One reason progress towards theimplementation of child-focused initiatives is patchy
is because of more or less successful modes of decen­
tralisation.205,206 Little evidence is available on the effects
of decentralisation on equity and efficiency of service
provision.207 Countries often aim to use decentralisation
to enhance local democracy, reduce bureaucracy, andpromote client-oriented services (including high-income
Nordic countries, such as Denmark and Sweden,208
and lower-middle income countries, like Kenya209 andIndonesia210). In countries with weak governance arrange­ments and budgets, such as Sierra Leone, fractured
national mechanisms for child protection systems can beamplified locally211 because of weak staff performance,
poor understanding of cultural and social norms, andnegative perceptions of central government.212 Similarly,
coordination efforts for child protection in South Sudan
have been hindered by a decentralised system with
unclear channels for com­munication across the national
and local governments.213 While devolved responsibility tolocal government makes sense to link children’s families
and commu­nities to nation-wide initiatives, it requires
thoughtful support and strengthening of local systems.
Decen­tralisation is not a panacea, and it can be well or
poorly executed, but it does offer opportunities tostrengthen child health and wellbeing.
At the same time, local governments are meant to beaccountable to the communities they serve. Certain legal,
fiscal, and administrative frameworks are more effective
when it comes to incorporating community voice andaction, including that of children and youth. In Brazil,
participatory management councils, which are part ofmunicipal governments, are enshrined in the consti­tution,and municipal laws exist to support children’s councils,
which have a small budget at their disposal.214 In Nicaragua,
child and youth participation in local governance isfacilitated by support from family and teachers, alliances
between local authorities and civil society, and leadershipin children.111 However, such municipal councils might beharder to create and sustain if not protected by the law.
Similarly, child-friendly cities are those whose systemof governance is committed to fully implementing therights enshrined in the CRC. They translate national
commitments into local action, often making insti­tutional,
legal, and budgetary transformations. For example, in
Alexandria, Egypt, a child-friendly city initiative launchedin 2006 established a coordinating mechanism tostrengthen the protective framework for children, result­ing in the identification and referral of more than7000 children at risk to appropriate services.215 However, in

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23

The Lancet Commissions

many LMICs, governments that ratified the CRC do nothave sufficient financial resources and political capital tosupport systemic reforms called for by the treaty.216 In
the poorest countries, budgets might remain unspentor be reallocated elsewhere. Efforts to support childfriendly cities are often spearheaded by non-governmentorganisations, such as Child in the City, or development
agencies, such as UNICEF, and not by local authorities
themselves. These deficits can be mitigated by enhanced
national political prioritisation of children.

Successful multisectoral governance at local level: the devil is in
the detail
Local multisectoral governance represents a missed
opportunity for efforts around child health and wellbeing.
Multisectoral collaboration might be easier to achieve in
local government given that different departments andpersonnel are often closely located and know one
another.217 Barriers to collaboration between local govern­
ment and civil society organisations, citizen groups, andthe private sector might include structural, procedural,
financial, professional, and legitimacy issues.218 However,solutions do exist, for example barriers associated withtraditional hierarchical governance arrangements can beovercome by so-called network governance formations, inwhich a broader group of experts meets to solve problems
in a neutral space, rather than some actors fulfilling theorders of others.219
Where local initiatives for children’s wellbeing have
proven sustainable and effective, certain conditions thatencourage multisectoral action have been in place. In areview of Overseas Development Institute case studies,
multisectoral partnerships and action with community
groups, schools, places of work, and local interest
clubs were particularly effective when there was clear
decentralisation and task-shifting. Joint governance andservice delivery models across education, water andsanitation, and other sectors were associated withimprovements in health, equity, and more efficient useof resources.188,220 Local governance can also link multiple
sectors and governmental jurisdictions, and mobilise
and convene communities and institutions, by attracting
and empowering local champions and social entre­
preneurs for child and youth wellbeing. In the UK
support for multisectoral approaches (ie, between healthand education), used local champions to establish
partner­ships, plan action jointly, and promote therequired programme changes.221
Building strategic and operational capacity enables
local authorities to operate autonomously. Effective
programmes use strategic partnerships to take advantage
of power distributed through networks and influential
actors in the broader economy. Long-term partnerships;
shifts from programmatic to systemic approaches;and networking with school boards, law enforcement,
local business, and parent groups are essential to help
local authorities. Another example are the after-school
24

programmes for sports and other activities developedin the USA, developed when municipal leadershipconvened, built a vision, and used community mobi­
lisation to leverage local policies and infrastructure, evenin the absence of financial resources.222 More broadly,
political leadership and public participation were iden­tified as the most important factors for multisectoral
action across all stages, from initiation of an endeavour
towards maintaining interest during the implementation
phase.217,223 Feedback loops to inform higher levels ofgovernment are also needed to allow scale-up of local
innovations in successful programmes.

Global governanceIn the age of globalised public health, many threats
to child wellbeing cross national boundaries. Global
governance arrangements influence a government’s
capacity to deliver for children, but these global schemes
are currently fragmented and require urgent attention to
be more effective.

Redesign global governance for the SDGs with the narrative ofchildren at the centre
Global health governance is a highly contested sphere,224
and a powerful new vision has yet to replace child survival,
used as the dominant heuristic from the 1990s throughthe Millennium Development Goals era.225 Nominallyorganised around the Survive-Thrive-Transform frame­
work of the Global Strategy for Women’s and Children’s
Health (2016–2030);134 nonetheless, global governance forchild health and wellbeing is fragmented and disjointed.
Although the CRC offers a framing focused on rights,
some orga­nisations have argued that the case for children
should be based on wellbeing, with a focus on object­
ive and subjective assessments of life satisfaction.226,227
Others say the rights and wellbeing framings are compa­
tible, or offer framings focusing on human capital andcapabilities.228
All of these frameworks capture important aspects of
the health and welfare of children, but to-date few haveoffered a comprehensive narrative that conceptualises
placing children’s health and wellbeing at the centre of
the SDGs and the notion of sustainability.229 Such aframing is urgently required, not only to propel political
momentum and provide a common vision for inter­national organisations, national governments and civilsociety institutions, but also to breathe life into reforms ofthe global governance architecture, including the UN.
The SDGs disperse discussion of the child across multiple
goals—an intentional decision because the SDG agenda
is meant to be indivisible and integrated. But, despitemuch rhetoric, international institutions have not beentransformed and have seen their budgets stagnate, andglobal governance remains structured to deliver theMillennium Development Goals rather than the SDGs.230
As the key UN agencies concerned with children’s
health and wellbeing, UNICEF and WHO must lead on a

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The Lancet Commissions

new and integrated SDG agenda, with children at thecentre. The leadership of these agencies must heed
recent learnings about global health networks, which aremost effective when they strategically frame their issue
and succeed in establishing political coalitions that
extend beyond the health sector.231 Findings from the
Global Health Advocacy and Policy Project suggest thatwhile new technical advances, global agreements, or
initiatives to counter industry can be key in fomenting
global movements, in all cases, success is predicatedupon collective action taken by united stakeholders who
had previously worked in isolation. To unite diverse
stakeholders in the SDG era, child health and wellbeing
must be framed both as preconditions and outcomesof sustainable development, to involve other sectors in
an integrated manner.232 Fortunately, the connections
between child health and other SDG priorities are strong
and reciprocal: the first step to establishing partnerships
between sectors is to map these connections and assess
their strength and directionality.233
International organisations largely pursue sectoral
rather than holistic strategies to advance the rights andwellbeing of children. They focus not on the child per se,
but rather on discrete aspects of child wellbeing—healthor specific diseases, education, nutrition, care, protection,
violence, youth employment, or another concern—despite
the fact that these dimensions are intertwined.234–236 Some
organisations appear to be exceptions to this sectoralorientation, such as UNICEF and Save the Children;
but even these institutions divide themselves into mul­
tiple programmatic areas. Sectoral divisions parse prob­
lems to make them manageable; for example asking
an immunisation programme to promote literacy is
unreasonable, but suggesting that interactions withchildren and families around immunisation could provide
an opportunity to address other social concerns aroundthe child is plausible. Integration must be achieved at an
institutional level: UN institutions, such as WHO and
UNICEF, should be leaders in creating partnerships
internally, with each other and with other UN and inter­national institutions, modelling what will be required
nation-wide to work across sectors. Specific technicalexpertise on organisational design and management
might be needed from experts in this area, backed by astrong mandate from institutional leadership.

Making global governance work for countries
Since Jan, 2017, António Guterres, UN Secretary General,
has tried to reduce fragmentation by bringing together the
UN architecture to enhance lateral collaboration. Separate
UN funding streams, turf wars, duplication of plans, andbureaucratic inefficiencies abound. An umbrella strategy
across agencies could enable multiple actors to work intandem for the child and their families, provide concrete
strategies to deliver entitlements, and uphold principles
pertaining to rights and access to services. To lead on
this agenda, WHO must reorient from its historicallybiomedical vision and work with UNICEF to engage withministries other than departments of health. The UN
Committee on the Rights of the Child, the expert bodytasked with monitoring compliance with the CRC, could
also play a role in supporting the roll out and manage­
ment of such a strategy to achieve the agenda laid out inthis Commission. Whether such coordinated action can
succeed in pushing forward this programme will be themeasure of our global leaders’ ability to go beyond theusual ways of doing business to fulfil our responsibility
towards children and their future.
One major and well known obstacle to more coordi­
nated global governance is that the priorities of global
institutions often do not align with the needs of individual
countries.237,238 Institutions like the World Bank, theUnited States Agency for International Development,
The Vaccine Alliance, the Global Fund, and the Bill &Melinda Gates Foundation possess major financial andtechnical resources, which their leaders often use to, in
effect, impose priorities on national governments. Global
bodies are often criticised for being insufficiently attentive
to the expertise and understanding of local needs and local
actors. The result is a plethora of initiatives concerning
the child, which do not necessarily align with national
priorities, and divide and distort governmental attention
and resources.227 Commitments made by global leadershipbodies (WHO and UNICEF) in 2018 have the potential tomitigate many of these challenges, but their realisation isstill pending.239
Global norms, such as the ones considered andadvocated for in this Commission, are often refracted
and altered when translated to regional, national, andlocal governments, a process that has been described asnorm localisation.240 The legitimacy and authority of
global norm-setting exercises, including Commissions
published by The Lancet, rarely reach implementationlevel. Over the past few decades, regions have become
substantially more important sites of cooperation in thearchitecture of world politics.241 Regional bodies might
be useful in mediating and translating proposed norms
around child wellbeing, sustainability, and the SDGs.
Regional bodies can also advance policy issues in waysthat can inform global policies and recommendations, asseen with the work on data protection and online privacy
for children by the EU, advocacy for malaria control
by African Union, or the support of the South Asian
Association for Regional Cooperation for child nutrition
initiatives.

Summary
Here, we reviewed challenges and opportunities for
improved governance at national, subnational, and global
levels, and discussed how flatter, networked models mightneed to replace traditional hierarchical modes to imple­
ment the multisectoral SDG agenda for children. The
fragmented global governance architecture also needs
major surgery, with a shift towards the involvement

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The Lancet Commissions

Panel 8: Regulating commercial marketing to children—
key messages• In countries around the world, children are highly exposedto the marketing of products that are harmful to theirhealth and wellbeing, through techniques that exploit
their developmental vulnerabilities• Children’s online exposure makes them vulnerable to the
exploitation of their data, images, and person; however,internet access also creates opportunities for accessible
and effective health promotion activities• Ample evidence shows that voluntary self-regulation byindustry does not work
• Adding an Optional Protocol to the Convention on the
Rights of the Child on the regulation of commercial
marketing would be a strong step towards protecting
children from its harmful effects, and should be pursued bya broad coalition of countries, UN agencies, and civilsociety organisationsof regional bodies. We now extend this discussion of
improved governance structures to the commercial sector.

Regulating commercial marketing to children
Unregulated commercial activity poses many well
documented threats to children, not least environmental
ones. However, commercial marketing of products thatare harmful to children represents one of the mostunderappreciated risks to their health and wellbeing(panel 8). We have examined the harms children sufferfrom commercial marketing, looked at the insufficiencyof voluntary regulation, and propose a political process tocontrol commercial marketing to children by developing
an Optional Protocol to the CRC (ie, an additional
component to the treaty that must be independently
ratified).

Children are enormously exposed to harmful commercial
marketingChildren around the world are exposed to severe threats
from the commercial sector, by advertising and mar­ket­ing that exploits their vulnerability, by governments
not regulating products that harm their growth anddevelopment, and by use of their data and images without
their knowledge and permission. According to Kickbusch
and colleagues242 approaches to health promotion have“totally underestimated globalised corporate power com­bined with its global marketing onslaught and its trans­
national influence on political decision making,” adiscussion that has yet to be explicitly extended to children.
Countries and civil society organisations have not beenable to check the power of commercial entities, especiallymultinational corporations, which exacerbate social andhealth inequities.243
Awareness is growing of the harm of products marketed
to adults for use by children. For example, inappropriate
26

use of breastmilk substitutes is associated with lowered
intelligence, obesity, and increased risk of diabetes andother non-communicable diseases, collectively accounting
for an estimated loss of $302 billion.244 But marketers
also target children specifically. Marketing of products tochildren and adolescents provides excellent dividends
for companies, driving household spending, and creating
brand loyalties across the lifespan. Large companies
incorporate the science of the life course approach into
their marketing, to achieve the adherence and fidelity ofchildren to capture future consumption. This life course
brand loyalty constitutes an even more valuable target than
the spending children currently direct or influence.
Children around the world are enormously exposed toadvertisements: the average young person in the USA
sees 13 000–30 000 advertisements just on televisioneach year.245 A systematic review showed that the mostcommonly reported persuasive techniques used on
television to promote food to children were the use ofpremium offers, promotional characters, nutrition andhealth-related claims, the theme of taste, and theemotional appeal of fun.246 Additionally, the channels toreach children and adolescents have grown and diver­sified, often blurring the line between entertainment andadvertising. Social media advertising has exploded in thepast decade; however, little research is available tounderstand the effects of reaching children directly withcommercial messaging.247 Newer techniques, such as theuse of so-called kidfluencers (social media endorsement
deals for children and teenagers), are barely on the radarof parents and regulators.248 Although children younger
than 7–8 years old are understood to believe what
they see and not to recognise the persuasive intent ofcommercial advertising and marketing, much less isknown about how emerging technologies potentiallyexploit children’s developmental stages for the purposesof profit making.
Children are the frequent targets of commercial
entities promoting addictive substances and unhealthy
commodities, including fast foods and sugar-sweetened
beverages, but also alcohol and tobacco, all major causesof non-communicable diseases.249–252 Unhealthy foodadvertising on television is an important contributor tochildhood obesity, with attendant effects across thelifespan. A review of 23 studies in Latin America reported
that advertising exposure was associated with a preference
for and purchase of unhealthy or low-nutritional value
foods by families and children with high body-massindex, overweight, and obesity.253 A study, published in2016, showed that the link between television viewing andpoor diet was strongest for children who watched themost commercial television, and for those who wereactually exposed to advertise­ments embedded withinprogrammes.254 In Iran, food advertising during children’s
programmes is dominated by food items that arepotentially harmful to oral health,255 as are nearly twothirds of food adverts during UK children’s television.256

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The Lancet Commissions

One study has also expressed concerns that toy advertise­ments on television, which target children, promotesedentary play.257
Children worldwide are also highly exposed to adver­
tising for products nominally for use by adults only, suchas alcohol, tobacco and e-cigarettes, with exposure toadvertising associated with greater consumption. In
Australia, alcohol advertising and audience viewing data
were purchased for all football, cricket, and rugby league
TV programmes for 2012, with a cumulative audience of
26·9 million children and adolescents, and 32 million
young adults. Results showed that children and adol­
escents were exposed 51 million times to alcohol adverts,
with 47% of this exposure occurring during the daytime.258
In a study of 11–14 year olds from Los Angeles, CA, USA,
African-American youth were exposed to an average of
4·1 alcohol adverts per day and Hispanic youth were
exposed to an average of 3·4 alcohol advertisements
per day, nearly twice as many as non-Hispanic whiteyouth, who were exposed to 2·0 advertisements per day.
Girls of all ethnicities were exposed to 30% more
alcohol advertisements than boys.259 Furthermore, exist­
ing inequi­ties are reproduced by marketing to thenext generation of consumers (eg, in the USA, AfricanAmerican youth viewed approximately 50% or more
adverts for unhealthy foods than did white youth of thesame age).260 Children in LMICs are also highly exposed:
in a sample of 2423 5- and 6-year-olds in Brazil, China,
India, Nigeria, and Pakistan, 68% could identify at least
one cigarette brand logo, ranging from 50% in Russia to
86% in China.261
E-cigarettes are a new but worrying threat, particularly
in HICs. Exposure to e-cigarette adverts was prevalent
in US youth, who had medium-to-high exposure to
e-cigarette adverts from the internet (38·6%), newspapers(29·6%), shops (53·2%), and TV (35·4%).262 E-cigarette
advertising is not regulated in the USA, where youth
exposure to television e-cigarette advertisements, mea­
sured by target rating points, increased by 256% from2011 to 2013,263 with young adult exposure increasing by
321% over the same period. Adverts for these products in
the USA reach more than 24 million young people.264
Additionally, new technologies are exacerbating andcreating new threats to children that are not well under­stood. Gambling is a potentially large and unaddressed
public health challenge for children.264,265 The publichealth harms associated with gambling include anxiety
and stress, disruption of work or study, and relationshipconflict and breakdown. Moreover, children becomesocialised to gambling at an early age, with indications
that exposure is associated with consumption inten­
tion.266 The UK has 340 000 adult problem gamblers and1·7 million more people suffering some harm—in acountry where one in eight children aged 11–16 years
follow a gambling company on social media.267 In the UK,
as in most countries, gambling adverts on TV sport
events, which are accessible to children, are unregulated.

In Australia children had detailed recall of sports betting
advertisements and an extensive knowledge of sports
betting products and terminology.268

Children’s online exposureChildren’s online exposure is nothing short of enormous.
A review in the UK, published in 2018, showed thatchildren aged 5–15 years, spend on average 2 h online ona weekday and 3 h per day at the weekend.269 Children
aged 11–16 years post on social media 26 times a day,adding up to tens of thousands of posts by age 18 years.270
At the same time parents of children aged up to 13 years
share an average of 100 photos and videos of their childeach year.271 Between 2010 and 2015 the global volume ofdata increased eight-times and by 2020 the introductionof new technologies will increase the volume 40-times.272
Online behaviour can bring both harm and benefits tochildren. Although some studies have found that social
media use is not predictive of impaired mental healthfunctioning,273 social media is increasingly understood ascreating or exacerbating risks around young people’s
self-esteem, wellbeing, and risky behaviours.274–276 Social
media can affect children’s sleep, mental and physicalhealth, and their social lives. In a systematic review of
the rela­tionship between internet use and self-harmand suicidal behaviour, online exposure was found tonormalise self-harm, trigger abnormal behaviour andcom­petition between users, or act as a source of con­tagion
and harmful information for vulnerable indivi­
duals.277
More commonly, children and young people develop
so-called problematic use of the internet, a proposedumbrella term for a range of repetitive impair­ing behav­
iours,278 including excessive and compulsive video gaming,
compulsive sexual behav­
iour, bullying, gambling, andsocial networks use. The health and societal costs ofproblematic use of the internet across the lifespan are
unknown, but they could be huge. Exposure to violent
pornography is also a major concern and attempts toregulate access by age are often easily bypassed.
Vulnerable youth can also be targeted for radicalisation
by militant groups, which occurs daily in many countries,
across all income groups and security situations. Child­
ren are more easily intimidated and easier to control,
physically and mentally, than adults. Children are also
more inclined to show loyalty to authority figures.279
Militant groups develop precise propaganda strategies togenerate empathy and highlight the advantages ofjoining the group, which can include sta­tus and prestige,
smart uniforms, and weapons. Social media platforms,
including email, chat rooms, e-groups, message boards,
video recordings, and applications are popular grooming
and recruitment tools.280 Much more research andattention is needed to protect children and young people
from the negative effects social media can have on theirrisk-taking behaviours, mental health, and wellbeing.
However, the internet can bring great benefits throughcrisis support, reduction of social isolation, delivery of

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The Lancet Commissions

therapy, and outreach. Young people use social media tocommunicate their distress, particularly to peers. Social
media is a potentially accessible, inexpensive way to have
conversations about mental health, including to promotehealth-seeking and reduce isolation.281 Online friends canbe an important source of social support for LGBT, queer
or questioning, and intersex youth, and a growing amountof literature suggests that the internet can be a safe havenfor some young people belonging to sexual minorities.282
For families of children with disabilities and illnesses
like cerebral palsy, social media can provide a platform
for emotional support and forming connections, sharing
information and advice, and learning about services,283
but the quality of information is variable.284 Interventions
using artificial intelligence, such as chatbots, also havepromise in engaging adolescents about health issues,
such as obesity.285 Adolescents in particular are avid usersof technology for health, and can be reached throughdigital platforms with health messages and to participate
in chat and support groups online. More research is
required to understand ways to engage with thempositively in this medium.286

Use of children’s data and images by commerce
Online data has the potential to threaten a child’s safety,
development, and social interaction by normalising sur­veillance and increasing the risk of identity theft, fraud,and profiling. Children and young people are often thefirst to adopt new digital devices, services, and content,
as such they are especially vulnerable, especially todata manipulation through non-transparent and biased
algorithms (eg, based on race or ethnicity).
As a result, internet safety is a major concern, leading asmall but growing number of countries to make it part ofthe school curriculum. Data collected online includes
information given directly (eg, date of birth on a social
media profile), data given unknowingly (eg, captured
through web cookies or app-based location data), anddata that is inferred (eg, based on algorithms andpredictions analysed by companies). Data can also becollected through the internet of things, such as smart
speakers, internet-connected toys, or baby cameras;
and outside the home, from tracking watches, school
databases, study and behaviour apps, biometric data inschools, digital personal health records, travel passes,
and retail loyalty cards.269
Of course, data collection can have major benefits:
general practitioners and hospitals can share data toenable early identification of patients, audit of services
can improve accountability, analysis can prevent harmand promote positive health outcomes, and digital healthand development records can expedite care. But govern­ments and parents have major concerns, and manyquestions remain. Could data about a child’s language
development or educational performance play some rolein their university application outcomes? Will parents’
shopping habits affect the products and services their28

children are targeted with through advertising? Could
personal health data impair access to insurance infuture? And how safe is our data? Both public sector
bodies and commercial organisations have failed toensure privacy, transparency, security, and redress whenhandling children’s data. These concerns frequently
intersect (eg, when unregulated commercial activity
around internet-based genetic testing erodes publictrust in government programmes developed using more
rigorous scientific methods).287 Within the confines ofgovernment programmes, child centred-data raises bothpromising avenues and reasons to worry. For example,
predictive risk modelling has been embraced both as a
powerful tool for preventing and detecting child abuse,and criticised for individualising social problems andreifying oppressive frameworks of risk and abuse.288
In the UK, a database created in 2004 to enhance childprotection by improving information sharing between
services was decommissioned in 2010, following
criti­cisms by civil liberties groups that it was intrusive
and that the data was not securely stored.
The European General Data Protection Regulation has
attempted to tighten regulation on data protection andprivacy, including for children. Article 5 states that “datamust be processed lawfully, fairly and in a transparent
manner”289 and asks for special protection for children’s
data “for the purposes of marketing or creating per­sonality or user profiles and the collection of personal
data with regard to children when using services offereddirectly to the child.”289 The General Data Protection
Regulation goes further to protect children’s “right to beforgotten,”289 requiring age-appropriate privacy notices
and expressed consent for personal data to be used.
However, national governments face the unenviable taskof policing such regulation in a fast-moving field where
technological innovation is constant.

Voluntary regulation and existing global frameworks
are not sufficient
When seeking to protect children from harmfulcommercial exploitation, self-regulatory schemes have
had a very small effect on marketing to children or inprotecting use of their data. In Mexico, companies that
had signed up for self-regulation focused 93% of theiradvertisements on unhealthy food and beverages.290
In Canada companies promoted unhealthy foods andbeverages at similar rates during programmes withhigh numbers of child viewers, whether or not they
participated in the Canadian Children’s Food and Beverage
Advertising Initiative.291 In New Zealand, 88% of unhealthy
food advertisements were shown during children’s peakviewing times, in contravention of a number of selfregulation agree­ments by industry.292 In Australia, child­ren’s exposure to unhealthy fast-food advertising did notchange following the introduction of self-regulation.293 In
Spain, non-compliance with the Spanish code of selfregulation of food and drinks advertising directed at

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The Lancet Commissions

children under the age of 12 years has only increased
between 2008 and 2012.294 In Sri Lanka, of all food andbeverage-related adver­tisements, 78% were child-focused,
and of these 74% claimed health benefits, many of whichwere unsup­ported.295 In the USA only 1·4% of all childtargeted food adverts met all aspects of Interagency
Working Group on Foods Marketed to Children guide­lines.296 Additionally, alcohol brands popular with under­
age drinkers were more likely than others to advertisein magazines with high under­age readerships, despite
voluntary advertising industry guide­­­lines to protect
underage youth from high and dis­proportionate exposure
to alcohol advertising.297 Children in countries with weaker
government regulation might be at greater risk of advert
exposure: a 2008 report by the BBC suggested that British
American Tobacco, London, UK violated its own voluntaryinternational marketing standards in Nigeria, Malawi,
and Mauritius.298
Current national schemes of regulation and engage­mentwith commercial companies thus leave children highly
exposed. Although global institutions have offered some
guidance, and the EU has advanced some initiatives in thisrespect, shared principles are needed on good governanceof relationships with the commercial sector for protecting
the rights and wellbeing of children. As Woodrow and
Press reported,299 we must be wary of a so-called commer­
cialised view of childhood, and acknowledge the resp­
onsibility of societies to protect children from profit-making
at the expense of their wellbeing.
The CRC and associated Optional Protocols300 provide
standards against which agreements, services, and otheractions might be measured for their effect on children
and their rights, and a UNICEF300 toolkit out­lines steps
businesses should take to ensure that their interactions
with and influences on children do not adversely affecttheir welfare. Furthermore, global guidance is provided
by the UN High Commissioner for Human Rights,302 withadditional guidance on Children’s Rights and Business
Principles.303 These resources describe not only how com­
mercial enterprises, including their suppliers, adver­
tisers, marketers, and other associates should consider
child labour, protection, safety, and the local environ­ment in their activities, but also whether their activities,
products, or services adversely affect children’s wellbeing.
The responsibilities of national governments regarding
the relationship between the commercial sector andchild wellbeing has also been emphasised by global
authorities, with a General Comment issued under the
CRC in 2013.304
Notwithstanding these standards and guidance, asmall amount of evidence exists regarding businesses
considering child wellbeing in their decisions andactions, and many enterprises consider it irrelevant or
inimical to their activities.305 Existing guidance is seen as
soft and optional, with corporate behaviour dependent
on “reputational accountability and the coercive strengthof the web of accountability that is created throughnetworks of organisations and overlapping and comple­
menting soft law regulations.”306 Collins,305 in an extensive
mixed-method review of these issues, considers both thecommercial and rights perspectives, and cites the former
chair of the UN Committee on the Rights of the Child
Jaap Doek who described the “insincere eloquence” ofsome corporate social responsibility activities, and theinseparability of issues of corporate behaviour andchildren’s rights.
Given such considerations and rising concerns about
the health effect of inappropriate marketing practices,the Independent Accountability Panel under the Every
Woman Every Child initiative called for the adoption ofa legally binding global convention to regulate the foodand beverage industry in 2018.307 The Independent
Accountability Panel recommendations included spe­cific mention of the International Code of Marketing ofBreast-milk Substitutes (which is not a legally binding
instrument), and the need to bring together the Codeand other existing international standards on marketingfor and to children and adolescents. However, thedevelopment and adoption of such a treaty would likely
be a challenging process.

Initiating a political process to secure a legally binding
instrument on marketing products to and for children
A legally binding instrument to effectively regulatecommercial appeals to children would be a tangible anddesirable product of the SDG era, even if this only covers
part of the commercial harms to children, which also
includes products marketed to adults (such as guns andammunition and products containing chemicals harm­
ful to children—such as bisphenols, phthalates, and leadpaint), alongside a panoply of environmental harms thatthreaten life on this planet more generally.
Specifically, we propose adding an Optional Protocol
to the CRC regarding commercial marketing andtargeting of children, which would require national
governments to prohibit or regulate the types of productsthat should not be marketed to or for children (including
sugary beverages, unhealthy foods, alcohol, tobacco,e-cigarettes, gambling products, and breastmilk sub­stitutes); regulate specific methods of marketing tochildren (via television shows, games, and social media
used by children and youth, and sponsorship of youth
activities); and control the gathering and exploitation ofchildren’s data and images for com­mercial purposes.
Given the cross-border effects of commercial marketing,including through the internet and social media, and themultisectoral nature of the threat and needed response,
an Optional Protocol to the CRC adopted by the UN
General Assembly could address the transnational ele­ments of the problem and simultaneously drive national
action for legal protection.
A coalition of countries that have taken leadership inprotecting children from commercial harms, supported
by UN and civil society partners, could bring the

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proposal for adding a protocol to the CRC to the UN
General Assembly. Importantly, if such a protocol were
to be adopted, establishment of a new monitoringmechanism would not be needed because the existing
global oversight body under the UN Committee on
the Rights of the Child would automatically monitor
national implementation efforts. Having ratified the
additional protocol, national governments would need tosubmit periodic reports on implementation of theprovisions contained therein for review and scrutiny by
the committee, with observations and recommendations
made public. Regional bodies could be recruited tohelp steer implementation. National oversight could beinitiated through government departments responsible
for women’s and children’s development, commerce,
health, education, and media and information, withadditional independent monitoring by national humanrights institutions and civil society partners.
Such a protocol could build upon the precautionary
principle, introduced in environmental science in the
1990s in recognition of vulnerable groups, especiallychildren. The principle holds that when an activity raises
threats of harm to human health or the environment,
precautionary measures should be taken to mitigate thisaction, even if cause-and-effect relationships are notfully established scientifically.308 The precautionary
principle has been widely used by environmental scien­tists and regulatory authorities,310,311 but it has been
insufficiently applied to protect children from com­
mercial marketing—commercial entities can market
products to children with little evidence that they do notpose a threat to their wellbeing. Although evidence isemerging on the harms of commercial sector marketing
to children, the fast-paced nature of technologicalchange means children are actively being harmed while
the body of evidence grows.
One component of the precautionary principle is to shift
the burden of proof to the proponents of the activity. Thishas been called reverse onus, when the burden of proof(ie, safety) or the analytical burden is shifted from the risk
mitigator (ie, government regulators) to the risk gener­
ator (ie, industry).310 The EU’s Registrations, Evaluation,
Authorisation, and Restriction of Chemicals regulation
has adopted this approach to some extent. Given theconflicts between industry interests and public good
objectives, many researchers have reported that a spec­
trum of risk exists.311–313 These debates have led to guidancefrom UN committees on monitoring private sector
policies, practices, and partnerships relating to the foodindustry314 and global research consortia,313 which could
provide a framework for outlining a system of risk classi­
fication with respect to potential harms to children.
In addition, further work is needed to counter otherharms to children, such as those outlined in the Framework
Convention on Tobacco Control, efforts to reinforce
the International Code on Marketing of Breast-milk
Substitutes, unhealthy food advertising and sponsorship30(reported by Swinburn and colleagues)315 and fossil fuels,
which go beyond the purview of this Commission.
Experiences with regulating tobacco and sugar suggestthat direct regulation of industries whose behaviour
adversely effects children will be difficult.316 Progress intobacco control, including the adoption of the Framework
Convention on Tobacco Control, was hard fought overdecades, with corporate efforts to discredit the evidence
linking tobacco con­sumption or exposure with ill health.
Implementation of the tobacco framework was hamperedby global conglomerates with enormous resources to fightregu­lation of tobacco product marketing and sales, and bycountry governments protecting local producers. Reports
have emerged of similar efforts to distract lines of researchor discredit scientific evidence of links between sugar
consumption and non-communicable diseases by thesugar-sweetened beverage industry.317 These efforts will
likely be redoubled given increasing global calls for taxes
on sugar, tobacco, and alcohol to reach the SDGs.318
Further, implementation of such treaties might be slow to
evolve because of challenges in domestic courts stemmingfrom the interests of industries and corporations, which insome cases have acquired the same rights as people tofight government regulation.319
Such potential obstacles are all the greater given thatmany multinational corporations have resources larger
than some national governments and they are willingto defend their presumed rights in global tribunals,
using existing agreements, such as those developed by
the World Trade Organization. Furthermore, country
governments are often faced with competing incentives,
such as promoting business and commercial enterprises,
even those involving unhealthy products, in the interestof economic development. New international law on this
topic would aid governments to apply and strengthen
domestic legal frameworks, including consti­
tutional
law, in the interest of children’s health and wellbeing.
Notwithstanding its likely arduous gestation, an Optional
Protocol to the CRC to protect children from commercial
marketing would also attract many proponents, andwould provide a strong precedent across other sectors forbalancing public goods and commercial interests.
Meanwhile, indirect efforts that heighten publicawareness of related risks (eg, banning advertising of or
public communication on harmful products, or theirconsumption in public; taxation; and public advocacy
or awareness-raising) have been successful in changing
public opinion and corporate behaviour, and have sur­
vived corporate challenge in the courts. While any suchtreaty is being negotiated, global awareness of the rightsof children to be protected against such influences mustbe raised through similar indirect efforts.

Summary
We reviewed the many potential and actual harms tochildren from commercial marketing, via traditional
advertising and in the digital space, and proposed a

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The Lancet Commissions

process for adopting an Optional Protocol to the CRC toprovide a strong protective riposte. We now step backto examine the broader data and accountability landscapefor children in the SDG era, and look at how to monitor,
review, and act on data to achieve child health andwellbeing goals.

How to monitor, review, and act on SDG progressfor children?
Compared with the Millennium Development Goals,
the SDGs encompass a more comprehensive view ofdevelopment, which poses greater challenges for thedata and information required to make the best policy
choices, track SDG progress, and ultimately, deliver on
the targets of the global goals.320 The data needs forchildren range from monitoring survival, intervention
coverage, and disease prevalence to indicators related
to growth, education, and wellbeing, including socio­
economic and environmental determinants of health.
Despite poor-quality systems for data collection, ana­
lysis, and information dissemination in most LMICs,
the number of goals has doubled, from eight Millennium
Development Goals to 17 SDGs, with 232 indicatorsand 169 targets. Reporting requires collation of hugely
diverse data sources for social, political, economic, andenvironmental measures, and disaggregation of these tomonitor equity (panel 9).

Addressing the data gap for children
Focused on leaving no one behind, the SDG agenda
places the world’s most vulnerable and marginalised
people—including children—at the top of the global
development agenda. UNICEF categorises the childrelated indicators around five dimensions of children’s
rights: survive and thrive; learning; protection fromviolence and exploitation; safe and clean environment;
and a fair chance in life;321 we use the same five categories
to describe indicators. The roadmap for achieving theSDGs for women’s, children’s, and adolescent’s health islaid out in the Global Strategy for Women’s, Children’sand Adolescents’ Health (2016–2030).17 The strategy
focuses on three main domains: survive (end preventable
deaths), thrive (ensure health and wellbeing), and trans­
form (expand enabling environments).17
Of the 232 SDG indicators, 47 are directly relevant tochild health and wellbeing (appendix pp 5–18). Indicators
have been classified into three tiers by the Inter-Agency
and Expert Group on SDG Indicators based on theavailability of data and standardised methodologies
for assessment. Of the 47 child-related indicators, 17 aredesignated tier 1, 21 tier 2, and 9 tier 3 (figure 7), suggestingthat 30 (64%) of the child-related indicators are notregularly pro­duced by countries, or that definitions andstandards for measurement have not been developed.
Even in instances where data are available, there might
be too few datapoints to establish a trend or calculate
projections towards targets.

Panel 9: Monitoring, reviewing, and acting on the
Sustainable Development Goals (SDGs)—key messages• Data needs for measuring and monitoring progress
towards child health and wellbeing targets are high,but most countries do not regularly collect comparable
data for a large proportion of child-related SDG indicators• Because disaggregation is key to make sure no one is left
behind, greater investments are needed to strengthen thesystems for the collection and use of routine andadministratively collected data to complement reportingon equity, for which household surveys are the main source• Child flourishing can be measured for all countries using
indicators that are reported, but a complete picture
requires accounting for sustainability and the health of
our planet, as in our proposed child flourishing andfutures profile• Data openness and citizen participation, including
youth-led initiatives, can harness new energy and capacities
to overcome the barriers to collecting data towards SDG
progress, as well as fulfilling rights to participation,
co-ownership, and community responsibility

All child indicators (aggregate)

30%
54%

Every child survives and thrives
Every child learns

48%

14%

Every child is protected from violence,
exploitation, and harmful practices

22%

Every child lives in a safe and clean
environment

25%

22%
38%

43%

8%
43%

64%
37·5%

Every child has a fair chance in life

14%
37·5%

100%
Tier one

Tier two

Tier three

Figure 7: Child-related Sustainable Development Goals indicators by tier status
Tier one=indicator is conceptually clear, has an internationally established methodology and available standards,
and data are regularly produced by countries for at least 50% of countries and of the population in every region
where the indicator is relevant. Tier two=indicator is conceptually clear, and has internationally establishedmethodology available standards, but data are not regularly produced by most countries. Tier three=nointernationally established methodology or standard are available for the indicator, but methodology andstandards are being (or will be) developed and tested.

The indicators that are most regularly reported bycountries are related to poverty and health (especiallymortality and health care intervention cov­erage). The
newer and least well established indicators on thrive andtransform (including climate, sustainable cities, genderequality, and quality education) have large data gaps,
these gaps also exist for the survive indicators for children
older than 5 years.
The availability of data on child-related SDG indicators
varies between LICs, MICs, and HICs (figure 8). Dataavailability in LICs is highest in Senegal and lowest inComoros. Of the MICs, Mexico has reported on thegreatest number of child-related indicators and Kosovo
the least, and of the HICs, Norway has reported on the

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31

The Lancet Commissions

greatest number of indicators. However, no country hasreported on more than 70% of the child-related SDG
indicators. For many HICs the low number of indicators
reported on is because they are already meeting thetargets. Analysing the amount of available data for eachindicator within the five domains of children’s rights
across all country income groups (figure 9) shows thatfew, if any, data are available for indicators on education,
violence and exploitation, and safe environment.
SDG indicators take a life course approach and include
measures of health and wellbeing from preconception
to the end of adolescence, while acknowledging there
are intergenerational effects on health and wellbeing(figure 1). However, the indicators vary in terms of
quality and reliability. Birth and infancy indicators
have better data availability than late childhood andadolescence indicators. For example, very few LMICs
report data on indicators related to violence (physical,
sexual, and psychological) for adolescent women(indicator 5.2.1 and 5.2.2). Information on the prevalenceof child marriage (5.3.1), child labour (8.7.1), literacy andnumeracy (4.1.1), and information communication
technology literacy (4.4.1) are also infrequently reported(appendix pp 5–18 for a summary of each child-related
SDG indicator).
Data on children are derived from multiple sources,
including household surveys, routine facility reporting,facility assessments, and administrative data (such as
health workforce and financing data, civil registration, andvital statistics). Facility reporting systems are an import­antsource of data for output and service utilisa­­tion data, but
quality can be problematic.322 33 of the 47 child-related
indicators are dependent on national household surveys
as their primary data source. However, household
data, mainly obtained through the imple­
mentation of
Demographic and Health Surveys and Multiple Indicator
Cluster Surveys, cannot meet the demand for annual

monitoring because they are done every 3–5 years, or for
subnational data, especially at the district level, because
most national surveys are designed to provide only
regional estimates.323 Furthermore, lag time can be morethan a year between data collection and reporting, andeven longer for datasets to be available for secondary
analysis.
The global SDG indicator framework has an over­arching
principle of data disaggregation for income, gender, age,
race, ethnicity, migratory status, disability, and geographic
location.324 Although SDG indicators that are compiled
from household survey data can be disaggregated (eg,gender and geographic location) population samples areoften too small to obtain reliable subgroup estimates.325
Data for global reports on national and regional estimates
are often too sparse to be disaggregated; in other cases,
analyses are restricted to strata with sufficient data, such as
rural or urban location and gender. Some stratifications
might be sensitive to collect in certain contexts, such as for
race, ethnicity, religion, or sexual orientation.
Disaggregation is essential to make existing gradientsobjective and tangible. To view the situation of children
through national averages risks masking their realities,
especially when attempting to pinpoint the inequities
and violations of rights that affect them. Disaggregationmust be done sensitively, for example to avoid ignoringtransgender and non-binary people when classifying by
sex. However, children with disabilities, refugee andmigrant children, children belonging to indigenous
groups, or other ethnic or racial minorities, among
others, are at risk of being left behind if they remain
invisible in national monitoring processes. Only 18% ofcountries have reported on indicator 4.a.1, whichmea­­sures the proportion of schools with access toadapted infrastructure and materials for students
with disabilities, and several of those countries reportthat no schools have suitable adaptions. The Washington

Country completeness (%)≤15
Data not available
16–30
NA
31–45
46–60
61–69

0

1800 3600 km

Figure 8: Availability of data on child-related Sustainable Development Goals indicators by country
The figure shows the percentage of child-relevant SDG indicators with at least one datapoint reported since 2015.

32

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The Lancet Commissions

Group on Disability Statistics, a UN-sponsored group,and UNICEF, in partnership with Disabled People’s
Organizations, have developed a new way of gathering
information on child disability. New questions to iden­tify
children with disability have been included in UNICEF’s
Multiple Indicator Cluster Survey and are being piloted
in around 40 LMICs.321

A
3.b.1a DPT3
3.b.1a PCV3
3.b.1a MCV1
3.8.1 Essential
health services

How to get good-quality data

3.7.2 Adolescentbirth rate

Every child survives and thrives indicators

3.7.1 Family planningwith modern
methods
3.3.3 Malaria
incidence
3.3.1 New HIV
infections (<5 years
and adolescents)
3.2.2 Neonatal
mortality
3.2.1 <5 years
old mortality
3.1.2 Skilled birthattendance
3.1.1 Maternalmortality
2.2.2 Wasted
2.2.2 Overweight
2.2.1 Stunted
2.1.2 Food insecurity

B

Every child learns indicators

In 2016, 22 countries did national SDG reviews andsubmitted reports to the UN High-level Political Forumon Sustainable Development. In 2017, the number
nearly doubled to 43 countries. Many LMICs struggled topresent national and disaggregated statistics for mostchild-related SDG indicators (figures 8 and 9). The realityof national planning and budgeting processes means thatinterventions and outcomes for which data are scarce do
not get prioritised.
For many LMICs the data burden is far too onerous.
Many government departments and national statistical
offices face capacity and financial constraints, making datacollection and completion of regular surveys difficult.323
Consequently, reports do not give a comprehensive pictureof child wellbeing.326 More­over, given the number of
informal dwellers, surveys in urban locations are far moredifficult to do than surveys in relatively stable ruralcommunities.
Targeted investments are required to strengthen
national information systems within and across sectors,
particularly in countries with weak information systems.
UN agencies, such as WHO and UNICEF, work withacademic institutions and carry out country consultations
to produce global health estimates on child health andwellbeing using complex modelling processes. In 2018,
WHO announced a collaboration with the Institute of
Health Metrics and Evaluation to produce the Global
Burden of Disease estimates. Funding agencies, espec­
ially the Bill & Melinda Gates Foundation, are making
major investments in global health estimation. These
efforts are important for regional and country com­
parisons and for global advocacy purposes. None­theless,the estimates can give a false impression of an abundanceof data.327 The reality is that most data on children, usuallyfrom household surveys, are out of date or subject to longrecall periods. Analysis and presentation are rarely
helpful to authorities for planning subnational action
and strategies.327
Large data gaps can be filled with greater involvementof citizens and communities in monitoring progress andenabling local action and accountability.328 Furthermore,
we must focus on improving the collection of data for
populations that are hardest to reach or for which little
data exists, such as children with disabilities. Strength­
ening of national information systems is a priority thathas been largely ignored. Little investment has been
made into building capacity for collection and use of
information and for enhancing accountability locally.

4.a.1(d) Adaptededucational
infrastructure
4.6.1 Functional
nummeracy andliteracy
4.5.1 Parity indicesin literacy
4.4.1 Youth andadults with IT skills
4.2.2 Organised
early learning
4.2.1
Developmentallyon track
4.1.1.c.i Reading
4.1.1.c.i Maths
0

10
20
30
40
50
60
70
80
90
100
Percentage of countries with at least 1 datapoint reported since 2015 for the SDG indicator

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Low income

Middle income

High income(Figure 9 continues on next page)

33

The Lancet Commissions

This is not just a technical issue, but a rights-based
public policy imperative deriving from the principle ofinformation as a global public good.
Applying a life course approach to monitoring requires
the integration of data systems for mothers and children.
C
16.9.1 Birthregistration 3
16.2.3 Sexual
violence by age 18

21

31

23

5

16.2.2 Human 3
trafficking

32
9Every child is protected indicators

16.2.1 Physicalpunishment
6

8.7.1 Child labour
8.6.1 Youth notin educationor employment

59

14

15
9

40
14

8.5.2 Employment
rates

51

5.6.1 Women haveinformed decisions in 3
sexual & reproductive health5.3.2 Female genital
mutilation

64

80

20

17

4

5.3.1 Child marriage

31

17
14

5.2.1 IPV girls

Every child lives in a safe and clean
environment indicators

D
13.1.1 Effects ofnatural disaster

29

37
39
97
96
98

7.1.2 Clean fuels
and technology
6.2.1 Population
using safe sanitation

92
92

3.9.1 Mortality due
to air pollution

90

93

97

97

Every child has a fairchance indicators

E40

1.3.1 Social protection
system coverage (%)
9

1.2.1 Children living
onthe poverty line

20

0

73

39

10

1.1.1 Children
living in HH withextreme poverty

54

40

54

10
20
30
40
50
60
70
80
90
100
Percentage of countries with at least 1 datapoint reported since 2015 for the SDG indicator
Low income

Middle income

High income

Figure 9: Completeness of child-related SDG indicators data for each of the five each domains of children’s
rights (at least one datapoint since 2015): every child survives and thrives (A); every child learns (B); every childis protected from violence, exploitation, and harmful practices (C); every child lives in a safe environment (D);every child has a fair chance in life (E) from low-income, middle-income and high-income counties
IT=information technology. SDG=Sustainable Development Goal. IPV=intimate partner violence. HH=household.
See appendix pp 5–18 for full indicator definitions.

34

In the siloed global aid architecture used nowadays,
integrating systems is difficult to achieve with separate
programme-specific monitoring and funding streams329(eg, for newborn health or family planning), which
compete within a narrow space for attention andfunding.164,236,239
Some SDG indicators could be captured throughnational civil registration and vital statistics systems or
routine information systems (eg, immunisation coverageand birth registration), which is why LMICs require
support to strengthen their health management infor­
mation systems. Brazil is one example of a MIC that has
invested in strengthening its routine health information
system as part of a process of broader health system
reform. This included the establishment of the SistemaÚnico de Saúde Hospital Information System, theMortality Information System and the Live Births
Information System, which was launched in 1990 toprovide standardised data collection procedures at all
hospitals; by 2002 the Live Births Information System
included data for 86% of all livebirths.322 The data fromthese systems is brought together using interinstitutional
coordination to build and standardise indicators, anddisseminate basic data, indicators, and health statusassessments in an organised manner through theInteragency Health Information Network.330 Brazil has notundertaken a Demographic and Health Survey since 1996,
opting instead to undertake their own nationally planned
and implemented surveys that enable the country toreport on the majority of child related SDG indicators. As
more MICs shift away from Demographic and Health
Surveys to independent national surveys, a need exists toensure that such national surveys adopt internationallystandardised question­
naires and measurement proto­cols, so that their results can be compared with those ofother countries.
The open source district health information system 2331
is the world’s largest health management information
systems platform and is operational in 67 LMICs, and it isalso used in some countries (eg, Zambia) to capture
education data. Very few indicators (3 of 47) use data fromroutine sources; improving these routine systems will be along process, and it is absolutely essential to invest in
doing so. The district health information system captures
data on services at facilities, from primary to tertiary level,
and in many countries also includes activities by com­munity health workers and environmental health officers.
The district health information system is an importantsource of information for SDG monitoring, but it does notcontribute to reporting on many SDG indicators forseveral reasons. First, the district health information
system only provides information on individuals who
access care; therefore, they are not representative of theentire population, especially where health care utilisation
is low; second, data from the private sector is usually notincluded; third, district health information system data is
owned by governments and access to the information

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The Lancet Commissions

for agencies compiling global monitoring databases
requires negotiations around data ownership; and finally,
the quality of routinely collected health information isoften poor.s
Despite these challenges, district health information
system 2 could monitor health service coverage indicators
in settings with high utilisation of services or reliable
information from censuses on population denominators,
and for local monitoring via the development of auto­mated score cards for community-facility monitoring
activities.
Again, many SDG indicators cannot be monitored
through routine information systems that only include
citizens who attend a health facility or a school. These
data are not nationally representative because they do
not capture those citizens who do not attend thesefacilities. Indicators measuring essential issues such as
nutritional status, intimate partner violence, childpoverty, and clean fuel access will continue to requirehousehold surveys.325 A balance is needed between
reducing the existing reliance on surveys and overloading routine systems, on the basis of a holistic
assessment of each country’s policies around data andinformation systems.

A child flourishing and futures profile: a new way tounderstand country progress
The ultimate aim of the SDGs is to ensure that all children
are able to flourish and lead happy, meaningful lives, now
and in the future. If countries are to create national andsubnational accountability towards the SDGs, particularly
regarding child health and wellbeing, they need a sum­mary index of country performance for planning andcross-country comparison. We constructed a new national
profile to measure the foundational conditions for child­
ren aged 0–18 years to survive and thrive today (table),and act as a proxy measure of future environmental
threats to children based on projected greenhouse gas
emissions excess in 2030. These two measures of childflourishing and environmental sus­
tainability threats
combine to produce our child flourishing and futures
profile (figure 10).

Constructing the flourishing index from the SDG indicators
Our flourishing index was constructed first by comparing
dimensions proposed by major conceptual frameworks
for child wellbeing and human flourishing in HICs,
MICs, and LICs, namely UNICEF’s Five Dimensionsof Children’s Rights in the SDG Era;321 the UN Global
Strategy for Women and Children’s Health;17 Martha
Nussbaum’s basic capabilities for human flourishing;332
VanderWeele’s seven dimensions of human flour­ishing;333
the systematic review of indicators of child wellbeing
by Pollard and Lee;334 and framework of positive child
wellbeing by Lippman and colleagues.335 We selectedindi­cators—primarily SDG indicators—and aggregation
methods to match those domains.

Rank Flourishing*

Surviving Thriving World Bank classification

Central African Republic

180

0·06

0·01

0·38

Low income

Chad

179

0·10

0·03

0·28

Low income

Somalia

178

0·12

0·03

0·40

Low income

Niger

177

0·12

0·06

0·26

Low income

Mali

176

0·14

0·06

0·33

Low income

Guinea

175

0·17

0·08

0·35

Low income

Nigeria

174

0·18

0·08

0·38

Lower-middle income

South Sudan

173

0·19

0·11

0·33

Low income

Sierra Leone

172

0·22

0·13

0·35

Low income

Afghanistan

171

0·22

0·13

0·38

Low income

Mozambique

170

0·24

0·16

0·38

Low income

Liberia

169

0·25

0·16

0·40

Low income

Benin

168

0·25

0·18

0·35

Low income

Democratic Republic of the Congo

167

0·26

0·16

0·43

Low income

Guinea-Bissau

166

0·26

0·16

0·43

Low income

Madagascar

165

0·27

0·18

0·40

Low income

Malawi

164

0·28

0·21

0·38

Low income

Burkina Faso

163

0·29

0·21

0·40

Low income

Côte d’Ivoire

162

0·29

0·20

0·43

Lower-middle income

Angola

161

0·29

0·20

0·43

Lower-middle income

Lesotho

160

0·30

0·21

0·43

Lower-middle income

Papua New Guinea

159

0·30

0·28

0·33

Lower-middle income

Yemen

158

0·31

0·25

0·38

Low income

Cameroon

157

0·32

0·23

0·45

Lower-middle income

Burundi

156

0·32

0·21

0·50

Low income

Togo

155

0·32

0·23

0·45

Low income

Mauritania

154

0·32

0·28

0·38

Lower-middle income

Ethiopia

153

0·33

0·30

0·35

Low income

Uganda

152

0·33

0·25

0·43

Low income

Haiti

151

0·35

0·25

0·48

Low income

Congo

150

0·35

0·28

0·45

Lower-middle income

Sudan

149

0·36

0·30

0·43

Lower-middle income

Zambia

148

0·36

0·30

0·43

Lower-middle income

Eritrea

147

0·37

0·30

0·45

Low income

Zimbabwe

146

0·37

0·33

0·43

Low income

Tanzania

145

0·37

0·33

0·43

Low income

Nepal

144

0·38

0·35

0·40

Low income

Bangladesh

143

0·38

0·40

0·35

Lower-middle income

eSwatini

142

0·38

0·30

0·48

Lower-middle income

Comoros

141

0·39

0·35

0·43

Low income

Pakistan

140

0·39

0·35

0·43

Lower-middle income

The Gambia

139

0·39

0·35

0·43

Low income

Kenya

138

0·39

0·30

0·50

Lower-middle income

Laos

137

0·40

0·30

0·53

Lower-middle income

Senegal

136

0·40

0·35

0·45

Low income

Timor-Leste

135

0·43

0·33

0·58

Lower-middle income

Equatorial Guinea

134

0·43

0·38

0·50

Upper-middle income

Ghana

133

0·43

0·38

0·50

Lower-middle income

Vanuatu

132

0·44

0·43

0·45

Lower-middle income

India

131

0·44

0·45

0·43

Lower-middle income

Rwanda

130

0·45

0·38

0·53

Low income

Solomon Islands

129

0·45

0·50

0·40

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Lower-middle income(Table continues on next page)

35

The Lancet Commissions

Rank Flourishing* Surviving Thriving World Bank classification(Continued from previous page)
Guatemala

128

0·45

0·40

0·50

Upper-middle income

South Africa

127

0·45

0·40

0·50

Upper-middle income

Namibia

126

0·46

0·43

0·50

Upper-middle income

São Tomé and Príncipe

125

0·46

0·48

0·45

Lower-middle income

Gabon

124

0·47

0·40

0·55

Upper-middle income

Djibouti

123

0·47

0·43

0·53

Lower-middle income

Kiribati

122

0·47

0·53

0·43

Lower-middle income

Iraq

121

0·51

0·53

0·50

Upper-middle income

Myanmar

120

0·53

0·43

0·65

Lower-middle income

Suriname

119

0·54

0·53

0·55

Upper-middle income

Bolivia

118

0·54

0·45

0·65

Lower-middle income

Indonesia

117

0·54

0·48

0·63

Lower-middle income

Guyana

116

0·55

0·58

0·53

Upper-middle income

Dominican Republic

115

0·55

0·55

0·55

Upper-middle income

Cambodia

114

0·55

0·58

0·53

Lower-middle income

Bhutan

113

0·55

0·55

0·55

Lower-middle income

North Korea

112

0·55

0·45

0·68

Low income

Honduras

111

0·56

0·60

0·53

Lower-middle income

Philippines

110

0·56

0·55

0·58

Lower-middle income

Cape Verde

109

0·58

0·65

0·53

Lower-middle income

Ecuador

108

0·60

0·68

0·53

Upper-middle income

Venezuela

107

0·60

0·60

0·60

Upper-middle income

Botswana

106

0·60

0·60

0·60

Upper-middle income

Morocco

105

0·61

0·68

0·55

Lower-middle income

El Salvador

104

0·61

0·68

0·55

Lower-middle income

Egypt

103

0·61

0·63

0·60

Lower-middle income

Panama

102

0·62

0·60

0·65

High income

Nicaragua

101

0·62

0·65

0·60

Lower-middle income

Paraguay

100

0·64

0·60

0·68

Upper-middle income

Samoa

99

0·64

0·63

0·65

Upper-middle income

Tajikistan

98

0·65

0·63

0·68

Low income

Peru

97

0·65

0·65

0·65

Upper-middle income

Kyrgyzstan

96

0·66

0·58

0·75

Lower-middle income

Saint Vincent and the Grenadines

95

0·66

0·73

0·60

Upper-middle income

Belize

94

0·66

0·70

0·63

Upper-middle income

Fiji

93

0·66

0·68

0·65

Upper-middle income

Jamaica

92

0·66

0·68

0·65

Upper-middle income

Ukraine

91

0·66

0·68

0·65

Lower-middle income

Brazil

90

0·68

0·68

0·68

Upper-middle income

Seychelles

89

0·68

0·70

0·65

High income

Mexico

88

0·68

0·68

0·68

Upper-middle income

Tonga

87

0·68

0·63

0·75

Upper-middle income

Argentina

86

0·68

0·75

0·63

High income

Algeria

85

0·69

0·63

0·75

Upper-middle income

Mongolia

84

0·70

0·73

0·68

Lower-middle income

Saint Lucia

83

0·70

0·68

0·73

Upper-middle income

Colombia

82

0·70

0·73

0·68

Upper-middle income

The Bahamas

81

0·70

0·70

0·70

High income

Romania

80

0·71

0·65

0·78

Upper-middle income

Russia

79

0·71

0·78

0·65

Upper-middle income

Palestine†

78

0·71

0·75

0·68

Lower-middle income(Table continues on next page)36

For Surviving, we selected maternal survival, survivalin children younger than 5 years old, suicide, access tomaternal and child health services, basic hygiene andsanitation, and lack of extreme poverty. For Thriving,
the domains were educational achievement, growth andnutrition, reproductive freedom, and protection fromviolence. Each domain is measured by one or two key
trace indicators. Good availability of data for mostcountries was an important factor in indicator selection,
as was the need to shine a spotlight on issues including
violence against women, child marriage, stunting, or
educational achievement. Further details of index con­struction and scoring as well as individual indicatorvalues by country are available in the appendix pp 19–66.
Briefly, surviving and thriving indicators comprise thetwo main dimensions of our flourishing index (we also
use school education, which is a transform indicator
under the UN Global Strategy). Scores for surviving andthriving are calculated separately after categorising eachindicator and taking an arithmetic mean weighting
each indicator equally within each domain and eachdomain equally within each dimension. The scores foreach dimension are combined into an overall score using
a geometric mean. An overall score close to 0 indicatesvery poor, with 0·25 indicating poor, 0·50 neither poor
nor adequate, 0·75 adequate, and 1·00 good flourishing.
Scores and ranks were calculated for 180 individual
countries with available data (table). At the higher end of
the scale are HICs such as Norway, South Korea, and theNetherlands that typically satisfy the basic conditions forchild survival, but still have room for improvement onchild thriving. At the lower end of the scale are LICs,
such as Central African Republic, Chad, and Somalia,that perform poorly on both child survival and thriving;
generally, these countries perform worse on survival than
thriving. Countries in the middle of the ranking include
a mixture of income levels, such as Myanmar (lowermiddle income, 120th), Brazil (upper-middle income,90th), and Turkey (upper-middle income, 60th). In creat­
ing this index, we had to contend with large gaps indata availability with respect to indicators of childdevelopment, protection, and wellbeing. Many indicatorvalues, such as maternal mortality or injuries, weredrawn from heavily modelled data. This poses well known
problems because the validity of modelled estimates
depends on a combination of the validity of model
assumptions and model robustness to deviations fromits assumptions.336,337
In some instances, neither modelled nor raw data wereavailable. Indicators on opportunity for participation andvoice in local, national, and international affairs are also
largely absent from the SDGs. These domains are coreelements of a flourishing life across multiple conceptual
frameworks.332–334 Indicators of adolescent happiness, life
satisfaction, and positive peer relationships are missing,and indicators for practical reason, meaning, purpose,and autonomy are only represented for girls within

www.thelancet.com Published online February 18, 2020 https://doi.org/10.1016/S0140-6736(19)32540-1

The Lancet Commissions

indicators of female empowerment. Measuring these
constructs in children is complex because of their sub­jective and con­text-specific nature. Collecting informationand capturing the voices and experiences of children
is also difficult; parents or caregivers are often asked
to provide infor­
mation about their children, but thismight introduce bias because of long recall periods338 orsocial acceptability.339 Nonetheless, the global medical
community has called for indicators of people’s participa­tion in health systems to be included in the next setof SDGs.340
Furthermore, current population-based measures ofchild development rely predominantly on proxy measures,such as stunting and poverty. Accurate assessment ofchild development is needed to monitor developmental
progress from birth through to school entry.341 Data on the
proportion of children younger than 5 years who aredevelopmentally on track with regard to health, learning,and psychosocial wellbeing are available for 66 countries,
but this data currently excludes many LICs and HICs.342
Universal population based measures designed to quan­tify child development are urgently needed, particularly
for the youngest children. New tools for measuring earlychild development in children younger than 3 years old
are under development (panel 10).
Because of data limitations, we envision our childflourishing index as a first step in the process of raisingawareness regarding the need to measure and promoteconditions fundamental to child wellbeing. Our index isprimarily an illustrative tool for showing how SDG
indicators can be used to construct a measure of childflourishing at a national level. The index might constitutea base from which more comprehensive indices can be
developed as the depth and breadth of global monitoring
indicators expands. In the future, countries developing
strong subnational information systems might apply ourindex at district levels.

A proxy sustainability index for the future
Promoting today’s national conditions for children to
survive and thrive must not come at the cost of eroding
future global conditions for children’s ability to flourish.
Under widely used business-as-usual scenarios, there is
a 93% chance that global warming will exceed 4°C by
the year 2100.343 This would have devastating healthconse­quences due to disruption of water and ecosys­tems,
rising ocean levels, inundation of coastal cities and small
island nations, increased mortality from heatwaves,proliferation of vector-borne disease, and a crisis ofmalnutrition because of disruption to food production
systems.3
Both the 2015 Paris agreement and the Inter­governmental Panel on Climate Change have called on
governments to restrict warming to below 1·5°C.344
Achieving this will require substantial changes to global
economic, political, and social systems.344 Under real­istic assumptions about possible trajectories towards

Rank Flourishing* Surviving Thriving World Bank classification(Continued from previous page)
Azerbaijan

77

0·71

0·73

0·70

Upper-middle income

Georgia

76

0·71

0·70

0·73

Lower-middle income

Costa Rica

75

0·72

0·80

0·65

Upper-middle income

Libya

74

0·72

0·75

0·70

Upper-middle income

Lebanon

73

0·73

0·73

0·73

Upper-middle income

Maldives

72

0·73

0·80

0·68

Upper-middle income

Uzbekistan

71

0·74

0·70

0·78

Lower-middle income

Grenada

70

0·74

0·78

0·70

Upper-middle income

Albania

69

0·74

0·75

0·73

Upper-middle income

Sri Lanka

68

0·74

0·88

0·63

Lower-middle income

Mauritius

67

0·74

0·85

0·65

Upper-middle income

Uruguay

66

0·74

0·85

0·65

High income

Trinidad and Tobago

65

0·75

0·83

0·68

High income

Thailand

64

0·75

0·83

0·68

Upper-middle income

Iran

63

0·75

0·80

0·70

Upper-middle income

Jordan

62

0·75

0·80

0·70

Upper-middle income

Oman

61

0·75

0·80

0·70

High income

Turkey

60

0·75

0·78

0·73

Upper-middle income

Kazakhstan

59

0·75

0·78

0·73

Upper-middle income

Vietnam

58

0·75

0·73

0·78

Lower-middle income

Tunisia

57

0·75

0·73

0·78

Lower-middle income

Armenia

56

0·75

0·73

0·78

Upper-middle income

Moldova

55

0·75

0·73

0·78

Lower-middle income

Qatar

54

0·76

0·83

0·70

High income

Chile

53

0·76

0·83

0·70

High income

Turkmenistan

52

0·76

0·78

0·75

Upper-middle income

Barbados

51

0·76

0·78

0·75

High income

Antigua and Barbuda

50

0·76

0·78

0·75

High income

United Arab Emirates

49

0·78

0·90

0·68

High income

Serbia

48

0·79

0·75

0·83

Upper-middle income

Bahrain

47

0·79

0·90

0·70

High income

Cuba

46

0·80

0·83

0·78

Upper-middle income

Bulgaria

45

0·80

0·80

0·80

Upper-middle income

Malaysia

44

0·81

0·90

0·73

Upper-middle income

China

43

0·81

0·80

0·83

Upper-middle income

Kuwait

42

0·82

0·88

0·78

High income

Lithuania

41

0·82

0·85

0·80

High income

North Macedonia

40

0·83

0·83

0·83

Upper-middle income

USA

39

0·84

0·88

0·80

High income

Bosnia and Herzegovina

38

0·84

0·85

0·83

Upper-middle income

Latvia

37

0·84

0·83

0·85

High income

Saudi Arabia

36

0·85

0·93

0·78

High income

Belarus

35

0·85

0·90

0·80

Upper-middle income

Montenegro

34

0·85

0·88

0·83

Upper-middle income

Poland

33

0·85

0·85

0·85

High income

New Zealand

32

0·86

0·95

0·78

High income

Greece

31

0·86

0·93

0·80

High income

Slovakia

30

0·87

0·90

0·85

High income

Hungary

29

0·88

0·88

0·88

High income

Croatia

28

0·88

0·88

0·88

High income

Estonia

27

0·88

0·88

0·88

High income

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37

The Lancet Commissions

Rank Flourishing* Surviving Thriving World Bank classification(Continued from previous page)
Italy

26

0·89

0·93

0·85

High income

Slovenia

25

0·89

0·88

0·90

High income

Israel

24

0·90

0·98

0·83

High income

Cyprus

23

0·90

0·98

0·83

High income

Portugal

22

0·90

0·98

0·83

High income

Canada

21

0·90

0·95

0·85

High income

Australia

20

0·90

0·95

0·85

High income

Austria

19

0·90

0·95

0·85

High income

Malta

18

0·91

1·00

0·83

High income

Spain

17

0·91

1·00

0·83

High income

Finland

16

0·91

0·98

0·85

High income

Switzerland

15

0·92

1·00

0·85

High income

Germany

14

0·92

1·00

0·85

High income

Sweden

13

0·92

1·00

0·85

High income

Singapore

12

0·92

1·00

0·85

High income

Luxembourg

11

0·92

1·00

0·85

High income

UK

10

0·92

0·98

0·88

High income

Iceland

9

0·92

0·98

0·88

High income

Belgium

8

0·94

1·00

0·88

High income

Japan

7

0·94

1·00

0·88

High income

Denmark

6

0·94

0·98

0·90

High income

Ireland

5

0·95

1·00

0·90

High income

France

4

0·95

1·00

0·90

High income

Netherlands

3

0·95

1·00

0·90

High income

South Korea

2

0·95

1·00

0·90

High income

Norway

1

0·95

1·00

0·90

High income*Flourishing is the geometric mean of Surviving and Thriving. An overall score close to 0 indicates very poor,

with 0·25 indicating poor, 0·50 neither poor nor adequate, 0·75 adequate, and 1·00 good flourishing.
†State of Palestine/occupied Palestinian territory, including east Jerusalem.
Table: Child flourishing index rankings

sustainable greenhouse gas emissions—so-called sharedsocioeconomic pathways344—models predict that global
carbon emissions need to be reduced from 39·7 giga­
tonnes to 22·8 gigatonnes per year by 2030347 to main­
tain even a 66% chance of keeping global warming
below 1·5°C.
A predicted world population of 8·1 billion by 2030347
corresponds to a target of 2·7 tonnes of CO₂ emitted per
capita by 2030 after adjusting for bunker fuels usedaboard vessels. This can be considered a minimum target
for high-emission countries because it allocates equal
per capita emissions to all countries irrespective of their
historical role in emitting carbon. Using data from the
Global Carbon Atlas,348 we can create a Sustainability
Rank that ranks countries on excess carbon emissions
compared with the 2030 target. This provides a convenientand available proxy for a country’s contribution tosustainability in future.
Although many HICs rank extremely highly on theflourishing (survive and thrive) index; they are near thebottom in terms of performance on contributions to global
ecological sustainability, and vice versa for LICs (figure 11).
38

For example, Norway, South Korea, and the Netherlands
are ranked number 1st, 2nd, and 3rd on current childflour­ishing, but these countries are 156th (Norway), 166th(South Korea), and 160th (the Netherlands) on global
sustainability list, all of them with per capita carbon
emissions more than 210% higher than the sustainability
starget for 2030. Therefore, the two country ranks provide
us with our child flourishing and futures profile, acombination of a country’s achievement on surviving andthriving today, with the damage they might cause throughgreenhouse gas emissions to children in future.

A focus on equity
Equity is essential to ensure that efforts to promotechildren’s present and future flourishing truly leave noone behind. The child flourishing and futures profile
paints a picture of differences in achievement between
countries. However, equity within countries acrossmultiple axes, including geographical, social, ethnic,
gender, and indigenous versus non-indigenous popu­
lations, is just as crucial. But data on these inequities isoften scarce, meaning that within-country differences
are often obscured, even though these often dwarf intercountry differences.
Equity data on child health and nutrition indicators is
primarily available for LMICs, but data on economic
inequality using the Gini coefficient is available formost countries (appendix pp 67–71). Plotting countries
by their income-based Gini coeffi­cient (a more appro­
priate measure of in­equality than consumption-based
Gini coefficient) against their child flourishing index
score shows that, generally speaking, poorer countries
with lower child flourishing scores tend to have greater
economic inequality (figure 12). However, exceptions
exist: the USA is a HIC that ranks as the 11th mostunequal country in the world (among countries forwhich we have data on income inequality). Moreover,the child flourishing rank of the USA (39th) is also poor
compared with many other HICs, and even some MICs.

Data and information for children at country and local
level
A framework for action and feedback between levels
Monitoring of SDG targets is only possible if governments
act efficiently and equitably, and citizens have the agency
to transform their communities. Although global moni­
toring initiatives have an important role, they are justone part of a larger bidirectional system of informationcollection, analysis, and feedback that includes com­munity, subnational, and national actors. Monitoring
progress towards the SDGs requires high-quality andcomplete population data to inform policy, service delivery,
and economic decision making. Increased attention andinvestment in strengthening national information sys­
tems within and across sectors, particularly in countries
that have historically had weak monitoring systems, is an
essential priority. This requires ongoing support for

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The Lancet Commissions

house­hold surveys, building national statistical capacity,and developing routine administrative systems and othersubnational data systems.349
We propose a framework outlining how SDG indicators
can be collated and monitored to enable accountability forchild health and wellbeing (figure 13). Four overarching
principles should guide country SDG monitoring plans.
First that data collected should be aligned with national
priorities. Second, data should be locally relevant. Third,
data should be timely and feasible to collect. Finally, theinformation should contain sufficient detail to enabledisaggregation by important measures of equity. Nationaldata, which contributes to global databases, comes largely
from household surveys and censuses. Data openness isessential, yet roughly half of surveys and censuses are still
not publicly available or are reported after long delays. Thisdelay means national planners often have to make decisions
on the basis of information that was collected several years
previously or cannot undertake disaggregated analysis(eg, by rural or urban area or measures of wealth status) to
inform targeted national plans.349 Subnationally, regional or
district planners and managers require locally relevant
information, representative of their geographic area, thatenables them to take decisions regarding the effectivefunctioning of facilities and services across sectors.
Individuals and communities want information toassess whether services meet their needs. Data generated
by citizens could be used to support improved monitoringof local sustainability activities and service delivery, as
well as the effectiveness of new policies from their local
government. But, what SDG indicators are suitable forcommunity monitoring? For example, monitoring accessto safe water and sanitation within schools, access topublic transport, and safe spaces for recreation withincommunities, and coverage of essential health services
are obvious candidates. Although data requirements vary
for different levels of decision making and action, they
are linked along a continuum with feedback loops andunderscored by a commitment to upholding child rights
and equity.

A dashboard for country action to improve child and adolescentwellbeing
Numerous global accountability frameworks exist to assesscountry progress towards the achievement of the SDGs.
Countdown to 2030 and its predecessor Countdown to2015 have played an instrumental and pioneering role inaccountability for women’s, children’s, and adolescents’
health, by generating country and equity profiles (among
other successes); the Global Strategy for Women’s,
Children’s, and Adolescents’ Health (2016–2030) alsotranslates the SDGs into concrete guidance on how toaccelerate progress. The nurturing care framework is
grounded in a rights-based orientation for promoting
early childhood develop­ment (for which there is an SDG
indicator). These components parallel those embedded in
the CRC, and include good health, adequate nutrition,

Child flourishing Excess CO2 emissions
index
relative to 2030 targets (%)
1–40
<0
41–80
1–100
81–120
101–200
121–160
201–300
161–180>300
Sustainability Flourishing
CO2 perrank
rank
capitaWorld Bank classification
Excess CO2
emissionsrelative to 2030
targets (%)

Qatar

180

54

49·18

1716

High income

Trinidad and Tobago

179

65

29·72

998

High income

Kuwait

178

42

25·24

832

High income

United Arab Emirates

177

49

24·66

810

High income

Bahrain

176

47

23·08

752

High income

Saudi Arabia

175

36

19·28

612

High income

Australia

174

20

16·90

524

High income

USA

173

39

16·24

500

High income

Kazakhstan

172

59

16·07

493

Upper-middle income

Luxembourg

171

11

15·93

488

High income

Canada

170

21

15·64

477

High income

Estonia

169

27

15·13

458

High income

Oman

168

61

14·06

419

High income

Turkmenistan

167

52

12·63

366

Upper-middle income

South Korea

166

2

12·08

346

High income

Russia

165

79

11·76

334

Upper-middle income

Singapore

164

12

11·34

319

High income

Iceland

163

9

10·39

284

High income

Mongolia

162

84

9·88

265

Lower-middle income

Germany

161

14

9·73

259

High income

Netherlands

160

3

9·63

256

High income

Japan

159

7

9·45

249

High income

Belgium

158

8

8·76

223

High income

Poland

157

33

8·56

216

High income

Norway

156

1

8·44

212

High income

Libya

155

74

8·37

209

Upper-middle income

Ireland

154

5

8·35

208

High income

Finland

153

16

8·32

207

High income

Iran

152

63

8·28

206

Upper-middle income

Malaysia

151

44

8·05

197

Upper-middle income

South Africa

150

127

8·05

197

Upper-middle income

Austria

149

19

8·01

196

High income

Israel

148

24

8·00

195

High income

New Zealand

147

32

7·65

183

High income

Bosnia and Herzegovina

146

38

7·60

181

Upper-middle income

Slovenia

145

25

7·02

159

High income

China

144

43

6·98

158

Upper-middle income

Bulgaria

143

45

6·93

156

Upper-middle income

Greece

142

31

6·81

151

High income

Slovakia

141

30

6·50

140

High income

The Bahamas

140

81

6·49

139

High income

Belarus

139

35

6·48

139

Upper-middle income

Seychelles

138

89

6·43

137

High income

Cyprus

137

23

6·37

135

High income

Spain

136

17

6·07

124

High income

Denmark

135

6

6·03

122

High income

Italy

134

26

5·99

121

High income

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39

The Lancet Commissions

Sustainability Flourishing
rank
rank

CO2 per
capitaExcess CO2
World Bank classification
emissionsrelative to 2030
targets (%)

UK

133

10

5·81

115

High income

Turkey

132

60

5·55

105

Upper-middle income

Antigua and Barbuda

131

50

5·54

105

High income

France

130

4

5·48

102

High income

Portugal

129

22

5·31

96

High income

Equatorial Guinea

128

134

5·30

96

Upper-middle income

Hungary

127

29

5·18

91

High income

Serbia

126

48

5·13

89

Upper-middle income

Iraq

125

121

5·08

88

Upper-middle income

Venezuela

124

107

4·99

84

Upper-middle income

Ukraine

123

91

4·80

77

Lower-middle income

Thailand

122

64

4·79

77

Upper-middle income

Switzerland

121

15

4·73

75

High income

Chile

120

53

4·69

73

High income

Lithuania

119

41

4·63

71

High income

Barbados

118

51

4·63

71

High income

Argentina

117

86

4·62

70

High income

Sweden

116

13

4·19

55

High income

Montenegro

115

34

4·18

54

Upper-middle income

Croatia

114

28

4·10

51

High income

Romania

113

80

4·06

50

Upper-middle income

Azerbaijan

112

77

3·89

44

Upper-middle income

Mexico

111

88

3·80

40

Upper-middle income

Latvia

110

37

3·68

36

High income

Suriname

109

119

3·65

35

Upper-middle income

Algeria

108

85

3·64

35

Upper-middle income

Maldives

107

72

3·60

33

Upper-middle income

North Macedonia

106

40

3·48

29

Upper-middle income

Botswana

105

106

3·44

27

Upper-middle income

Mauritius

104

67

3·38

25

Upper-middle income

Malta

103

18

3·35

24

High income

Lebanon

102

73

3·21

19

Upper-middle income

Cuba

101

46

3·18

17

Upper-middle income

Uzbekistan

100

71

3·10

15

Lower-middle income

Georgia

99

76

2·80

3

Lower-middle income

Gabon

98

124

2·73

1

Upper-middle income

Jamaica

97

92

2·69

–1

Upper-middle income

Guyana

96

116

2·67

–1

Upper-middle income

Grenada

95

70

2·56

–5

Upper-middle income

Panama

94

102

2·45

–9

High income

Tunisia

93

57

2·44

–10

Lower-middle income

Saint Lucia

92

83

2·42

–11

Upper-middle income

Ecuador

91

108

2·33

–14

Upper-middle income

North Korea

90

112

2·28

–16

Low income

Brazil

89

90

2·27

–16

Upper-middle income

Egypt

88

103

2·24

–17

Lower-middle income

Jordan

87

62

2·20

–19

Upper-middle income

Albania

86

69

2·18

–20

Upper-middle income

Vietnam

85

58

2·08

–23

Lower-middle income

Saint Vincent and
the Grenadines

84

95

2·02

–25

Upper-middle income

Peru

83

97

2·01

–26

Upper-middle income

Uruguay

82

66

1·98

–27

High income(Figure 10 continues on next page)40

responsive care­giving, security and safety, and oppor­
tunities for early learning. Other monitoring frameworks
are embedded in strategies like the Every Newborn Action
Plan, FP2020, the global Accelerated Action for the Healthof Adolescents strategy, and WHO’s new data portal formaternal and child health.
National governments should do formal, comprehensive
child effect assessments every few years (as previously
discussed); the question is how they can use these existingaccountability mechanisms to construct a simple tool thatcan graphically display current status and gaps at different
time intervals. A user-friendly tool would help highlightareas that are not on track and point to areas of successthat can be learned from. The tool would be used by those
involved in planning and policy making, or in advocating
for children’s rights. The groundwork is already welldefined: the ingredients needed for children to survive,
thrive, and flourish are spelled out comprehensively in the
CRC. Making these ingredients available for all requires
actions at multiple governmental tiers, across and within
sectors, and that specific actions will depend upon the
biological, social, and cognitive development of a child as
they get older, and the specific context where they live.
This Commission recommends the urgent develop­
ment of an adaptable country dashboard, based on
country consultation and expert advice. The elements fora dashboard will make the status of children visible andcatalyse investigation and action. The dashboard will bebased on the rights derived from the CRC and informedby the entitlements (discussed earlier), and will monitor
contextual variables that affect children’s wellbeing. The
CRC document emphasises environment and pollu­tion(Article 24),350 and the importance of environ­mentaleducation (Articles 29).350 Therefore, envir­onmen­tal
action must be monitored to understand how well we aredoing in creating a world we want for our children. As
such, this dashboard could be seen as a detailed,actionable companion to the child flourishing andfutures profile.
Because different development and life circumstanceissues exist for different age groups throughout child­hood (ie, different circumstances for infants, young
children, school-age children, and adolescents), the dash­board could use a 5-year age interval, a rough, but still
useful, categorisation that fits the convention of many
current data collection approaches. Criteria for the selec­tion of indicators could be those that are tier one in the
SDG framework or other relevant global accountability
frame­
works, or which have a strong evidence baseregarding what works for children and adolescents.
Agreement will be needed on how to use traffic-lightindicators (eg, green, yellow, red) and which cutoffs
should be used to reflect good progress, moderate
progress, and insufficient progress. A composite scorefor each country could be calculated by summing thenumbers of indicators coloured green, yellow, or red.
This would enable com­
parison of progress across

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The Lancet Commissions

Sustainability Flourishing
rank
rank

CO2 per
capitaExcess CO2
World Bank classification
emissionsrelative to 2030
targets (%)

Dominican Republic

81

115

1·98

–27

Upper-middle income

Armenia

80

56

1·93

–29

Upper-middle income

Bolivia

79

118

1·89

–30

Lower-middle income

Indonesia

78

117

1·84

–32

Lower-middle income

India

77

131

1·84

–32

Lower-middle income

Costa Rica

76

75

1·77

–35

Upper-middle income

Morocco

75

105

1·76

–35

Lower-middle income

Kyrgyzstan

74

96

1·73

–36

Lower-middle income

Colombia

73

82

1·66

–39

Upper-middle income

Namibia

72

126

1·60

–41

Upper-middle income

Belize

71

94

1·50

–45

Upper-middle income

Fiji

70

93

1·48

–45

Upper-middle income

Bhutan

69

113

1·44

–47

Lower-middle income

Tonga

68

87

1·32

–51

Upper-middle income

Lesotho

67

160

1·26

–53

Lower-middle income

Citizen engagement for action and accountability

Moldova

66

55

1·26

–54

Lower-middle income

Community action will be a key determinant of countries’
ability to improve children’s health and wellbeing andcreate a sustainable world for their future. Community
engagement was of course a fundamental principle of
the Alma Ata declaration,351 in 1978, and the World
Development Report 2004,352 which provided a central
message that public services can be improved by strength­
ening account­ability mechanisms between policy makers,
providers, and citizens, and proposed a framework for
public ac­count­ability. The SDG era, with universal rights
embodied in the goals, is an opportunity to revitalise acommitment to citizen participation and engagement
in monitoring with resultant action stimulated throughthe process.

Guatemala

65

128

1·23

–54

Upper-middle income

Philippines

64

110

1·22

–55

Lower-middle income

Angola

63

161

1·19

–56

Lower-middle income

Samoa

62

99

1·19

–56

Upper-middle income

Honduras

61

111

1·15

–57

Lower-middle income

Sri Lanka

60

68

1·11

–59

Lower-middle income

Cape Verde

59

109

1·10

–59

Lower-middle income

El Salvador

58

104

1·10

–60

Lower-middle income

Pakistan

57

140

1·01

–63

Lower-middle income

eSwatini

56

142

0·98

–64

Lower-middle income

Papua New Guinea

55

159

0·90

–67

Lower-middle income

Nicaragua

54

101

0·87

–68

Lower-middle income

Paraguay

53

100

0·86

–68

Upper-middle income

Djibouti

52

123

0·85

–68

Lower-middle income

Yemen

51

158

0·67

–75

Low income

Young people as citizen monitors

Benin

50

168

0·67

–75

Low income

Vanuatu

49

132

0·66

–76

Lower-middle income

Congo

48

150

0·65

–76

Lower-middle income

Mauritania

47

154

0·64

–76

Lower-middle income

Tajikistan

46

98

0·64

–76

Low income

Kiribati

45

122

0·63

–77

Lower-middle income

Zimbabwe

44

146

0·63

–77

Low income

Senegal

43

136

0·59

–78

Low income

Ghana

42

133

0·58

–79

Lower-middle income

São Tomé and Príncipe

41

125

0·57

–79

Lower-middle income

Nigeria

40

174

0·56

–79

Lower-middle income

Bangladesh

39

143

0·53

–80

Lower-middle income

Cambodia

38

114

0·50

–82

Lower-middle income

Côte d'Ivoire

37

162

0·48

–82

Lower-middle income

Myanmar

36

120

0·47

–82

Lower-middle income

Palestine*

35

78

0·47

–83

Lower-middle income

Sudan

34

149

0·45

–83

Lower-middle income

Timor-Leste

33

135

0·43

–84

Lower-middle income

Solomon Islands

32

129

0·39

–86

Lower-middle income

Togo

31

155

0·38

–86

Low income

Afghanistan

30

171

0·37

–86

Low income

countries, particularly across countries within the same
region.
Indicators should be disaggregated by key stratifiers (eg,gender, wealth quintiles, urban or rural location, ethnicity,and geographic region) where possible. A companion
national equity dashboard could be considered. The
indicator estimates or values would be presented alongwith the colour coding so that the user of the tool has aclear sense of which indicators in each domain or CRC
rights area are performing well or poorly. Only datapoints
for each indicator within the past 5 years will be shown on
the dashboard.
We believe such a dashboard should be a high priority
for governments and international bodies, and thatdevelopment assistance for poorer countries should
focus on strengthening data collection and analysis forpriority indicators.

In light of the large gaps in information on children, we
need transformative approaches to monitoring, including
community-collected information,353,354 grounded in livedexperiences, for credible and valid decision making on
local policies and programmes. This opens the oppor­
tunity for a new role for children and youth in measuringand monitoring their own wellbeing—as active partici­
pants. More than half the world is younger than 30 years,
many of whom are the hardest hit by poverty, climatechange, and inequality. Young people are frequently at
the forefront of change and development, through mass
citizen and digital activism. Moreover, for the SDGs tomeet the ambition of being truly trans­
formative, themonitoring and accountability framework, from local to
global authorities and agencies, must be people-centred,
inclusive, transparent, and participatory.353
Citizen-generated data can provide timely information
on issues that matter to the population, including those
who are margin­alised and hard to reach.355,356 Furthermore,citizen-generated data can fill gaps on issues of social
injustice, economic inequality, and more hidden concerns,
such as dis­ability or environmental degradation. Citizens,

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41

The Lancet Commissions

Sustainability Flourishing
rank
rank

CO2 per
capitaWorld Bank classification
Excess CO2
emissionsrelative to 2030
targets (%)

Mozambique

29

170

0·35

–87

Low-income

Cameroon

28

157

0·32

–88

Lower-middle income

Kenya

27

138

0·32

–88

Lower-middle income

Nepal

26

144

0·31

–89

Low-income

The Gambia

25

139

0·30

–89

Low-income

Laos

24

137

0·29

–89

Lower-middle income

Zambia

23

148

0·28

–90

Lower-middle income

Haiti

22

151

0·27

–90

Low-income

Tanzania

21

145

0·25

–91

Low-income

Comoros

20

141

0·23

–91

Low-income

Guinea

19

175

0·23

–92

Low-income

Liberia

18

169

0·23

–92

Low-income

Sierra Leone

17

172

0·18

–93

Low-income

Guinea-Bissau

16

166

0·18

–93

Low-income

Burkina Faso

15

163

0·17

–94

Low-income

Eritrea

14

147

0·16

–94

Low-income

South Sudan

13

173

0·15

–95

Low-income

Uganda

12

152

0·13

–95

Low-income

Ethiopia

11

153

0·13

–95

Low-income

Madagascar

10

165

0·12

–95

Low-income

Niger

9

177

0·12

–96

Low-income

Mali

8

176

0·09

–97

Low-income

Rwanda

7

130

0·08

–97

Low-income

Malawi

6

164

0·07

–97

Low-income

Central African Republic
Democratic Republicof the Congo
Somalia

5

180

0·07

–98

Low-income

4

167

0·06

–98

Low-income

3

178

0·05

–98

Low-income

Chad

2

179

0·05

–98

Low-income

Burundi

1

156

0·05

–98

Low-income

Figure 10: Ranking of countries and territories on sustainable levels of carbon emissions relative to 2030
targets as a measure of a country’s threat to future children, compared with child flourishing rank
*State of Palestine/occupied Palestinian territory, including east Jerusalem.
For more on Infomex see
https://infomex.org.mx/
gobiernofederal/home.action
For more on FixMyStreet see
https://www.fixmystreet.com/
For more on Trac FM see
https://tracfm.org/
For more on HarassMap see
https://harassmap.org/en/
For more on Ushahidi see
https://www.ushahidi.com/
For more on I Paid A Bribe see
http://www.ipaidabribe.com
For more on ForestWatchers see
http://cybermappr.unige.ch/
For more on Uwezo see
https://www.uwezo.net/

42

including children and youth, can use information to raiseaware­ness and realise rights, as outlined in Article 12 of
the CRC.350 Methods include participatory budgeting, childconsultation activities, and commu­nity-based monitoring
using score cards, social audits, mobile technology, andsocial media.357
Community-based monitoring ensures greater
account­a­bility in local service provision, underscored bya human-rights based approach357 that acknowledges
citizens as active agents of change who can solve prob­
lems in their own communities. A meta-case study
analysis of 100 case studies of citizen engagement from
20 countries found that 75% of all cases reviewed had
positive outcomes across four areas: con­struction of
citizenship; practices of citizen participation; responsive
and accountable states; and inclusive and cohesivesocieties. Negative outcomes included toke­nistic par­ticipa­tion, violent or coercive state responses, reinforce­
ment of social hierarchies, and exclu­sion.356 Althoughmost evidence for community mon­itoring comes fromsmall-scale studies,357 one random­ised controlled trial of
citizen report cards in Uganda showed 19% less nurse
absenteeism, higher immunisation uptake, a 16% higher
prevalence of facility utilisation, and a 33% reduction inchild mortality com­pared with com­munities who did notreceive the report card inter­
vention.358 A similar trial
done 10 years later, in a different region of Uganda, did
not achieve an effect on health care utilisation prevalenceor health out­comes (child mortality), but it did show amodest positive effect on treatment quality and patientsatisfaction, but this effect was not mediated throughcitizen moni­toring.359 More evidence is needed, but
positive examples exist, including an study from India
which shows how change can be driven through citizen
action (panel 11).
Many countries have embraced mobile technology, social
media, and online platforms for citizens to hold govern­ments to account. These initiatives are created or owned bycitizens or civil society and use open-access data to track
what is important to them.362 Some examples include
Infomex (Mexico), a web portal for the receipt, processing,and answering of information requests that citizens maketo state government entities; FixMyStreet (UK), TXT CSC(Philippines), and Trac FM (Uganda) provide mechanisms
for citizens to enquire, complain, or commend government
entities on service provision; HarassMap (Egypt), Ushahidi(global), and I Paid a Bribe (12 countries globally), whichcollect and track informa­tion on street harassment,
election violence, and petty corruption; ForestWatchers(international), a platform that collects data on defores­
tation; and Uwezo (Kenya, Tanzania, and Uganda) which
does annual, citizen-led large scale statistically repre­
sentative household assess­ments to measure literacy andnumeracy ability in children.
Young people have driven many highly effective social
movements over the past few years—including move­ments focusing on climate change and inequalities—
character­ised by self-organisation and the use of new
tech­nologies. Youth-led action can help or challenge
govern­ments to fill gaps in implementation of pro­grammes and policy (panel 5).362
These youth-led social accountability mechanisms
hold lessons for scaling up data collection more rapidly.
Citizen-generated data, especially of a qualitative nature,
on topics that affect people’s lives the most, does notneed to be representative to enhance our understandingof progress against SDG related targets. Furthermore,
the localised nature of most citizen-generated data isexactly why they add so much value. They shed light onwhat is actually taking place on the ground, which can bea far more useful tool for policy making than statistical
data based on national averages.353 Although technologies
hold much promise as tools for youth engagement, there
could be contexts in which use of technologies might
exclude certain youth from participation, such as those
who are illiterate or reside in remote areas without goodinternet or mobile network access.

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The Lancet Commissions

Panel 10: Case study: a new method for measuring early child development
Accurate assessment of child development is needed to monitor
children’s developmental progress from birth through to school
entry. Measurement tools are not necessary only for tracking
progress toward global policy goals, but also to inform resource
allocation and programming. However, population-based
measures of child development rely predominantly on proxy
indicators, such as stunting and poverty, and existing
instruments to measure specific domains of individual childdevelopment are often proprietary, with commercial publishers
controlling availability, cost, and standardisation. Neither theproxy nor the individual measures are adequate for programmeevaluation. As of 2019, no universal measures exist that assessdomains of development for children younger than 3 years old.
Three groups have recently developed new tools for measuring
domains of development in children younger than 3 years old:the Infant and Young Child Development group, the Caregiver
Reported Early Development Instruments group, and the Global
Child Development Group. The three measures are being
harmonised to develop a single measure, with a programmatic(long-form) version sensitive enough to allow quantification of
the relative effects of different interventions administered within
research programmes. This measure will be able to assess how
study participants change and respond to interventions over timeand scores will be comparable across studies; it will also permit
identification of populations of children at risk of poor
developmental trajectories.

Excess CO2 emissions relative to 2030 targets (%)

1000

Low income

Lower-middle income

Upper-middle income

The population level (short-form) version of the tool will containa maximum of 40 questions and will be of adequate
psychometric quality to inform the agreed indicator for
Sustainable Development Goal 4.2.1 by generating one score foroverall child development. It will be applicable to cross-sectional
assessment by lay people, take a maximum of 10 minutes toadminister, and be adequately sensitive to detect changes in childdevelopment over time and measure geographical, nutritional,
and socioeconomic differences at population level. It is envisaged
that the short-form tool will be integrated into Multiple Indicator
Cluster Surveys, Demographic and Health Surveys, and otherpopulation level surveys. This version, piloted in 2019, will allow
policy makers to map child development status worldwide anddraw attention to vulnerable populations in humanitarian
emergencies and other fragile contexts. The absence of a robust
early child development instrument has hindered efforts to trackprogress on ensuring that children thrive and not only survive.
A new method, approved by global experts, will enable policy
makers, investigators, clinical personnel, and other stakeholders
to assess interventions, examine data within and acrosscountries, and use contextual data for understanding associations
between predictors of development and scores on the tools.
Such efforts must be seen as accompanying and driving a pushtoward universal early detection of developmental disabilities
through appropriate screening programmes in all countries, notjust in high-income countries.

High income

Trinidad and Tobago

800

600

400

200

PanamaFranceCentral African Republic

0

Gabon

Myanmar
–200

0

0·10

0·20

0·30

0·40

Tajikistan

0·50
0·60
Child flourishing index

0·70

0·80

0·90

1·00

Figure 11: Countries’ level of carbon emissions relative to 2030 targets as a measure of a country’s threat to future children, compared with coefficient ofchild flourishing
Data for countries and territories reporting >1000% excess CO2 emissions are not shown in the figure.

Artificial intelligence as a support to social accountability
Artificial intelligence presents a major opportunity for en­g­age­ment and accountability in the next decade. Althoughgenuine concerns exist about artificial intelligence, thetechnology could be harnessed towards public good andhumanitarian action in many ways. A team of scientists at
Stanford University, Stanford, CA, USA, for example, havecombined machine learning with high-resolution satellite

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43

The Lancet Commissions

imagery to provide new data on socioeconomic indicatorsof poverty and wealth. Data from publicly available sources
can be applied with minimal training. Georeferenced dataon economic outcomes can provide important informa­tion on the distribution of poverty within countries toassist priori­
tisation in national planning and resource
allocation.363
Artificial intelligence has also been applied to youth
employment opportunities in South Africa, which has
one of the highest youth unemployment rates in the world.
Harambee, a Swahili word meaning all pull together, is
70

Low income

Lower-middle income

Upper-middle income

High income
BrazilIncome-based Gini coefficient60

50

Singapore

Nigeria40
Romania
Ethiopia

30

20

10

0

0

0·10

0·20

0·30

0·40
0·50
0·60
Child flourishing index

0·70

0·80

0·90

1·00

Figure 12: Countries’ level of income inequality, measured by the income-based Gini coefficient, comparedwith coefficient of child flourishing
N=85 countries.

a social enterprise that uses artificial intelligence tomatch youth with employment opportunities through geo­
graphical (including transport routes) and behavioural
metrics. Youth can register without any fee and more than
1 million youth have interacted with the platform.364
Whether information is citizen-generated or throughartificial intelligence or machine-learning processes,
sustained political engagement from local politicians,
decision makers, and the private sector is needed toprovide dialogue on solutions. Political engagement
should work across systems and sectors rather thanconsisting of one-off consultations addressing only
single sectors (eg, health). Data provides real leverage
to push for remedial action, but only if it is accompanied
by a review process to discuss the implications foraction. Without this engagement, social accountability
mechanisms will not lead to change and the power
divides between citizens and government will remain.365
Local government arguably has a disincentive to initiate
processes that make visible their failings and inefficien­
ces. However, from a human rights-based perspective, a
responsive local government should be open to engaging
with citizens and committed to implementing action toensure progress. We need to persuade politicians thatcoalitions with citizens are electorally popular andcan support transformational change for sustainable
development.
However, without political will, or a budget to support
the participation and actions of citizens, the highopportunity cost for the poorest and marginalised makes
their participation less likely, which could deepen equity
divides.357 Furthermore, the skills and capacity of bothgovernment and civil society organisations to support
Type of information collected

Tools and mechanisms for collecting andmonitoring data
• UN databases• Countdown to 2030 and Global Strategy

GlobalSDGs

Strategic goals

Impact indicators• Periodic household or special surveys, withsubnational district or regional
disaggregation• Census• CRVS

National
National strategies andbudgetary allocations• Routine information systems (eg, DHIS2)• District and council routine reporting• CRVS• Service availability mapping

Subnational
Operational plans, implementation
guidelines, andmonitoring• Household level CHW data and community
mapping• Youth reporting• Citizen report cards and CBM• Civil society group advocacy

Operational decisions

Process indicators
Community

Public mobilisation, mechanisms of accountability,
and citizen action• Country reports based on existing available
secondary data sources• Modelled estimates• Household survey data
• IPV and abuse• Child nutrition and feeding• Mortality data
• Poverty data
• Environment and transport• Routine health services• Social welfare systems• Early organised learning• Population and schools with access to WASH
• Health facility stock outs of essential
medicines

Figure 13: Framework of levels of information collection and utilisation
SDGs=Sustainable Development Goals. CRVS=civil registration and vital statistics. IPV=interpersonal violence. DHIS2=district health information system 2.
CHW=community health workers. CBM=community-based monitoring. We propose a framework for the collection and use of data for country SDG monitoring. It is
underscored by four over-arching principles: Alignment to national priorities, collection of locally relevant information, data that is timely and feasible to collect,and disaggregation of the data to ensure equity. The tools and mechanisms for data collection are outlined as is the type of information required at global, national,
subnational, and community levels. A feedback loop is critical to ensure that information is shared between different levels of decision making and action.

44

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The Lancet Commissions

Panel 11: Case study: community-based monitoring and planning of health services in Maharashtra, India
The National Rural Health Mission, launched in India in
April, 2005, has developed a comprehensive framework forcommunity-based monitoring, which aims to improve accessto high-quality health care, especially among poorer
populations and women and children in rural areas.
Community-based monitoring has been piloted in nine statesin India. In the state of Maharastra, 500 villages are covered
with plans to expand coverage to 750 villages.
Process
Village meetings, distribution of educational materials,
expansion and strengthening of village health committees(VHCs), and training of VHC members are used to enhancecommunity awareness and involvement in the process of healthaccountability. Multistakeholder community monitoring
committees are formed at primary health-care centres at blockand district levels. These committees include community
members, civil society representatives, elected politicalrepresentatives, and public health staff. Committee members
periodically collect information about health service delivery using
simple, pictorial semi-quantitative tools, and rate these throughpublicly displayed report cards, with each service being rated as
good, partly satisfactory, or bad. This data is collected both invillages (concerning outreach services) and in health-care facilities.
Public hearings, or Jan Sunwai, with mass participation areorganised at primary health-care centres, to present reportcards and cases of health-care denial. Health-care officials aresocial accountability are essential. To effectively sup­port community monitoring and social accountability,
civil society organisations need not only funding but also
literacy, technical skills, and knowledge of their rights.357
A collaborative approach between governments, civilsociety organisations, and other stakeholders can build
local social accountability mechanisms, in which citizens
and civil society play a decisive and formal role,366 andshould be embedded as part of the fabric of people’s dayto-day lives.

Summary
Here, we reviewed the data and accountability landscapearound child health and wellbeing, with a focus on how
to monitor, review, and act on data in the SDG era.
We reviewed the large gaps in current data processes andhighlighted the urgency of investment to strengthencountry information systems and capacities to collect,analyse and act on information capitalising on suitable
technology to reduce the burden on the public work force.
We then proposed some solutions, including a colourcoded child flourishing and futures profile (figure 10)
largely on the basis of available country data from theSDGs and carbon emissions, a compact and actionable
dashboard to help countries guide their action, andcitizen and youth-led monitoring to fill in the gaps. We

called upon publicly to respond regarding remedial actions.
Periodic state-wide events enable dialogue between civilsociety monitoring committee members and the state healthdepartment, seeking resolution of unresolved and systemic
issues, and help reinforce government support for thecommunity-based monitoring process.360
Outcomes
According to state officials, communities have increased publicawareness of their rights and empowerment to demand theserights. For example, public involvement in the Jan Sunwai(public hearings) has helped people realise the importance ofantenatal care check-ups and improved access and demand forthese services. There has also been enhanced accountability
from government officials who are confronted on an egalitarian
platform through dialogue, and who have addressedlong-neglected concerns, such as timely maintenance of clinics,
or taken action against corrupt providers.361
Community-driven data collection and periodic review has thepotential to effectively monitor the provision of entitlements,
medicine stocks, human resource deployment, quality of care
and attitudinal issues. However, more research is needed onwhether so-called bottom-up initiatives for community-driven
collection and use of data can effectively contribute tomonitoring and planning health policies and programmes,
including those relevant to children’s health and wellbeing,
and their potential for wider scale-up.

now turn to our conclusions and key recommendations(panel 1) around how to build a new global movement forchildren’s health and wellbeing at the centre of the SDGs.

Conclusion
We live in an era like no other. Our children face a futureof great opportunity, but they stand on the precipice of aclimate crisis. Working together, the world’s countries
have agreed to the SDG framework to usher future
generations into a cleaner, healthier world, but the SDG
agenda has yet to gain traction. Our challenge is great
and we seem to be paralysed.
This Commission proposes a new global movement toplace children at the centre of the SDGs. The CRC is theworld’s most ratified human rights treaty, showing thepower of children to unite us for the common good.
Working to improve children’s health and wellbeing canmotivate all of us to save our planet for them and for
ourselves.
In this Commission, we have purposefully taken a highlevel view of the problem of child health and wellbeing.
First, we have argued for a life course and intergenerational
approach to show that the benefits of intervening to
improve child health and wellbeing are multiplied manytimes over the life of the child and their descendants. The
economic and ethical case is unbeat­able. We also show

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45

The Lancet Commissions

how all sectors are responsible for children and lay out anagenda to unite them to work together.
Second, we operationalised this agenda by summarisinga set of entitlements for children that have already been
agreed upon by the world’s countries. We have also
described how families, communities, and governments
can mobilise to deliver them. The effort required isenormous, but if we cannot deliver for our children, whatis the measure of our civilisation?
Third, such an enormous collective project requires
governance. We have laid out the changes to governancerequired at national, local, and global levels. Given
that children’s health and wellbeing is the concern of
all sectors, we paid special attention to multisectoralcollaboration, as well as vertical coordination between
the various governance levels, to make sure our efforts
are synergised for maximum effect.
Fourth, we extended our discussion of governance todiscuss the regulation of commercial marketing. The
commercial threats to children’s health are dangerously
underappreciated, and we propose strong, specific actions
for global and national actors to protect children fromrapacious, unregulated commercial practices.
Finally, what gets measured, gets done. We have taken
a hard look at data and accountability under the SDGs,
and find that current efforts are severely wanting. Only
the participation of citizens, communities, and children
themselves can overcome the enormous data gaps for theSDGs, and because assessment of countries’ performancemust include a measure of sustainability to protect ourchildren’s future and their present, we have proposed achildren’s flourishing and futures profile to do just that.
Although awed by the scale of our task, this Commissionis also optimistic about our chances to change our world
for the better, for and with children. It will requirebold politicians, courageous community leaders, andinternational agencies that are willing to radically change
the way they work. No excuses, and no time to lose.
Contributors
Initial sections of the Commission were contributed by writing teams led
by ASG, JSh, TD, TP-J, and SA. LG designed the child flourishing index
and child futures profile. Full drafts were prepared by a core writing teamled by AC and SLD, based on contributions from writing team members.
All commissioners participated in creating Commission content, shaping
the overall Commission structure, writing and editing drafts, andformulating conclusions and recommendations. The Commission was
prepared under the general direction of HC, AMC-S, and AC. Further
data gathering and analyses were done by a supporting team listed in the
Acknowledgments. The authors alone are responsible for the views
expressed in this Commission and they do not necessarily represent theviews, decisions or policies of the institutions with which they areaffiliated, or those of WHO or UNICEF. The designations employed andthe presentation of the material in this publication do not imply theexpression of any opinion whatsoever on the part of WHO and UNICEF
concerning the legal status of any country, territory, city, or area or of its
authorities, or concerning the delimitation of its frontiers or boundaries.
Dotted and dashed lines on maps represent approximate border lines forwhich there may not yet be full agreement.
Declaration of interests
This Commission was funded by the Bill & Melinda Gates Foundation(Seattle, WA, USA) and all authors received support from the foundation46

via WHO to attend meetings. AB, KR, KS, NR, and JSi are employees ofWHO; and SP, DBH, and JR are employees of UNICEF. AC received
grants from WHO; and received personal fees from theBill & Melinda Gates Foundation. SLD received personal fees from theBill & Melinda Gates Foundation and WHO for the submitted
Commission and for work outside of the published work. LG received
personal fees from the Bill & Melinda Gates Foundation (via WHO).
YRS received personal fees from the Bill & Melinda Gates Foundation(via WHO). SSR received personal fees from the Bill & Melinda Gates
Foundation (via WHO). AB received funding from the Bill & Melinda
Gates Foundation. JB received a grant from the Bill & Melinda Gates
Foundation. JSi received a grant from the Bill & Melinda Gates
Foundation AG reports grants from the United States Agency forInternational Development Center for Accelerating Innovation andImpact, UNICEF, Rockefeller Foundation, and World Bank outside of
the submitted work. MT has received grants from the Conrad Hilton
Foundation outside of the submitted work. ASG is supported by theSouth African Research Chair’s Initiative of the Department of Scienceand Technology and National Research Foundation of South Africa(Grant No 82769) and the South African Medical Research Council.
All other authors report no competing interests.
Acknowledgments
The main funder of this Commission was the Bill & Melinda Gates
Foundation, which covered travel, accommodation, and meals for theCommission meetings, and the development of background papers andresearch assistant time; additionally, SLD, LG, YRS, SSR, and AC were
reimbursed for their writing time with grants. The grants weremanaged by WHO. Representatives of the Gates Foundation wereinvited to attend Commission meetings and were kept informed ofprogress, but they did not have a role in drafting the Commission.
In-kind support was also provided by staff at WHO and UNICEF.
Any opinion, finding and conclusion or recommendation expressed inthis material is that of the author and the National Research
Foundation of South Africa does not accept any liability in this regard.
AG is supported by the South African Research Chair’s Initiative of the
Department of Science and Technology and National Research
Foundation of South Africa (Grant No 82769) and the South African
Medical Research Council. We would like to acknowledge many othervaluable contributors to the Commission. At WHO, Benn McGrady,
Kate Robertson, and Marcus Stahlhofer provided valuable guidance on
legal aspects of the section on commercial governance. At UNICEF,
Tamara Rusinow, Jumana Haj-Ahmad, and Cristina de Carvalho
Eriksson provided inputs on children’s participation and engagement.
For our section on the child flourishing index and futures profile, we
consulted with Paul Ekins and Arkaitz Usubiaga-Liaño at the Institutefor Sustainable Resources, University College London, London, UK,
and Sir Partha Dasgupta at the University of Cambridge, Cambridge,
UK, regarding quantitative measures of sustainability. Enrique
Delamónica also provided input on the development of the childflourishing index. For the panel on children’s view of their wellbeing,
Paula King provided input from Mokopuna Māori children fromNew Zealand. Social Trends Institute (New York, NY, USA), Institutefor Family Studies (Charlottesville, VA, USA), Child Trends(Bethesda, MD, USA) provided data for analysis and figures on family
characteristics. Faith Popcorn provided input on imagining the futureof child health. Research assistants Jessika Johnston and
Rosemary Mamka Anyona provided essential background work forinitial stages of the report. Sarah Benn Gordon worked to distil the
General Comments to the UN Convention on the Rights of theChild into figure 3. Visualst, Maputo, Mozambique provided dataand graphic design for the figures. We also thank Joanna Vogel forsteering the Commission process for the first 9 months, Kate Rogers
for her support at UNICEF, and George Davis for essential
administrative support.
Editorial note: the Lancet Group takes a neutral position with respect toterritorial claims in published maps and institutional affiliations.
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