保健医療科学

2017Vol.66 No.4 p.395－401

特集：持続可能な開発目標（SDGs）に基づく今後のグローバルヘルス＜ Review ＞
Global policy directions for maternal and child health in the SDG era
Kenzo Takahashi 1), Marika Nomura 2), Sayaka Horiuchi 1), Hiroko Miura 2)
1）

Teikyo University Graduate School of Public Health2）

National Institute of Public Health, Division of International Cooperation

Abstract
In 2015, the sustainable development goals (SDGs) were ratified as the new global agenda for
the Millennium Development Goals (MDGs). In this article, we review the progress in maternaland child health achieved during the MDG period and the remaining challenges for the SDG
era, and stipulate the policy direction of global maternal and child health by referring to Japan’s
past experiences in maternal and child health improvement. During the MDG era, a series ofsystematic review in the academic journal, Lancet, and the results of randomized controlled trials(RCT) conducted in India established evidence-based intervention in the MCH field. Throughthe SDGs discussions, maternal and child health, which showed delayed progress comparedwith infectious diseases in the MDG era, drew attention as "unfinished agenda" at the UN level.
Reflecting this attention, the "Global strategy for women's, Strategies for children's and adolescentshealth (2016–2030)" was published. In the strategy, three aims were presented for maternal andchild health: survive, thrive, transform. On the other hand, in the SDGs agenda, the universal
health coverage (UHC), which simultaneously secures financial resources and an improvement in
the quality of services, was proposed and its contribution to maternal and child health expected.
However, considering the past experience of Japan in establishing the world’s first universal healthinsurance, the improvement of maternal and child health indicators, including infant mortality rate
reduction, started before the introduction of universal insurance coverage achievement. Moreover,
we surmise that such activities contributed as outreach and community empowerment by thehealth workforce including the public health nurses, practicing midwives, and volunteers. As
for UHC, it contributed primarily to financial resources for employing human resources such as
public health nurses. Consequently, for the improvement of maternal and child health, an evidencebased approach including systematic reviews and RCTs is needed. Additionally, reflecting Japan's
experience, we should revisit not only UHC promotion, but also community-level activities such as
primary healthcare with volunteer workers.
keywords: Sustainable Development Goals, Universal Health Coverage, Maternal and Child health,Community, Primary Health Care(accepted for publication, 11th July 2017)

Corresponding author: Kenzo TAKAHASHI
2-11-1, Kaga, Itabashi-ku, Tokyo, 173-8605, Japan.
Tel: 03-3964-3615
E-mail: kenzo.takahashi.chgh@med.teikyo-u.ac.jp

J. Natl. Inst. Public Health, 66 (4) : 2017395

Kenzo TAKAHASHI, Marika NOMURA, Sayaka HORIUCHI, Hiroko MIURA

I．Introduction
In 2015, the MDGs (Millennium Development Goals)
ended with significant "success" in HIV/AIDS control,
but several challenges remained, including maternal andchild health (MCH). Now, we have entered a new era of
Sustainable Development Goals (SDGs ). Through thedialogue on the post-MDG agenda for health, several
themes appeared, including non-communicable diseases(NCD ), universal health coverage (UHC ), and MCH. Fromthese discussions, one of UHC’s targets was its application
to MCH. Given the current global situation, MCH
improvement is considered as an important global challenge
to be continuously addressed. In this article, we thus review
the results of MDGs, the new SDG agenda, and Japan’s pastexperiences in these areas to better stipulate global policy
directions from the viewpoint of an MCH agenda.

II．Contribution of MDGs to MCH
During the MDG period, the global health community
saw several academic progresses as well as field trial
successes in MCH. Specifically, the Lancet played a majorrole with the publication of several systematic review
series, including "Child survival (2003)," "Neonatal survival(2005)," "Born too soon (2012)," and "Every newborn(2014).""
During the MDGs, MDGs 4 (reduce child mortality)
and 5 (improve maternal health) were trailing behind theprogress of MDG 6 (control of HIV/AIDS, tuberculosis, andother diseases). However, we recognize several progresses
in various academic fields, which strengthened the directionof the global health policy, including field activities. In fact,global evidence synthesis first started in 2003 when theLancet organized a "Child survival" series of articles [1].
In those articles, the global burden of child mortality
was disclosed for the first time: over 10.8 million children
die each year before their fifth birthday, mainly frompreventable causes, including diarrhea, pneumonia,
measles, malaria, HIV/AIDS, and the underlying cause ofunder nutrition, and mortality prevalence was shown to
be 41% in sub-Saharan Africa and 34% in South Asia [2].
Although these figures are decreasing, this geographicaldistribution remains unchanged. Additionally, almost 40%of under-five mortality was due to neonatal problems. In
short, this series verified the major cause of the under-five
mortality as infectious diseases and listed several effective
intervention measures, including breastfeeding, insecticide
treated materials, and vaccines [2].
In 2005, the Lancet also published "Neonatal survival
series," disclosed world’s situation of neonatal deaths.

396

The major cause of death was asphyxia and prematurity[3]. Since they were far from infectious diseases, theglobal health community advised that specific newborncare should be considered, which are different from theeffective interventions for under-five mortality reduction.
Consequently, MCH was transformed to maternal, newborn
and child health (MNCH) [4].
In the same year, the Journal of Perinatology published aseries of articles on a trial in Gadchiroli, a deprived area in
India. Through the "home-based neonatal care approach,"which taught how to treat sick babies using several
training materials, illiterate volunteers, including mothers,
conducted treatments such as neonatal resuscitationand sepsis treatment as appropriate, achieving almost
70% neonatal mortality reduction within the 10 years oftrial [5,6]. This outcome had an impact on global healthcommunities, and its strategy was adapted to UNICEF’s
Africa strategy. Since this trail was conducted as arandomized control trial (RCT), RCTs became popular in
MNCH, especially in Africa. The outcomes of the Gadchiroli
trial are supported by several systematic reviews, including
the Cochrane ones [7].
Reflecting these outcomes, the global health community
agrees the importance of including mothers in improving
neonatal survival rates.
In response to these evidences and discussions, thePartnership of Maternal, Newborn and Child Health(PMNCH, http://www.who.int/pmnch/en/) was establishedwith hundreds of stakeholders, including governments ofboth developed and developing countries, UN agencies
such as UNICEF and the World Health Organization (WHO),
private foundations such as the Bill and Melinda Gates
Foundation, and civil society measures such as the NGO"Save the Children." One of the important attainments of
PMNCH was the establishment of "Continuum of Care"concept, which advocates continuous care for women andbabies from the viewpoint of time (pregnancy-delivery-post
natal care/newborn-infancy-adolescent) and place (homecommunity-medical facilities), thus becoming the main
framework of MCH policies and community activities. Dueto the "Continuum of Care," there emerged discussions
that support the concept of MNCH, while RMNCAH(reproductive, maternal, newborn, child, and adolescenthealth) was subsequently introduced considering the
upstream of the causal relationships of "reproductive health"in relation to nutrition, family planning, and safe abortion,and "adolescent health" in relation to sexual education,
adolescent pregnancies, and young mental health as part ofa lifelong continuous care.
As an intervention model, a method called BP/CR (birthpreparedness/complication readiness) was developed

J. Natl. Inst. Public Health, 66 (4) : 2017

Global policy directions for maternal and child health in the SDG era
by JHPIEGO (Johns Hopkins Program for International
Education in Gynecology and Obstetrics) to ensure thesafety of home delivery. For BP/CR, successful outcomes
were reported mainly from Africa. A systematic review ofthis method has been conducted and proven to be effective
in reducing maternal and newborn mortality [8].
In September 2010, the "Every Woman, Every Child"movement (http://www.everywomaneverychild.org/) was
called for and established by the UN Secretary-General
Ban Ki-moon during the United Nations Millennium
Development Goals Summit, with a multi-stakeholder
approach, including governments, private sector, and civilsocieties. Its objective was to put an end to the preventable
deaths of women, children, and adolescents within ageneration.
As for the commitment of the Government of Japanfor MNCH, the Ministry of Foreign Affairs upgraded theso-called New International Health Policy in 2011. This
policy was also published in the Lancet under the "Foreign
Minister of the day" [9]. Based on this international healthpolicy, the EMBRACE (Ensure Mothers and Babies'
Regular Access to Care) model, which is a wide policy
support package to improve the environment for continuumof care, has been proposed [10]. JICA took part as a main
body, developed projects in Ghana, the outcomes being
gradually published. Overall, academics in global healthgradually focused on neonatal health.
In 2012, the Lancet series "Born too soon" raised
awareness on the importance of premature births incollaboration with WHO [11]. The Lancet also dealt withstillbirth in the "Every newborn" series in 2014 [12,13].
Subsequently, with the recognition that newborn survival
has lagged behind maternal and under-five survival, theglobal action plan "Every Newborn: An Action Plan to
End Preventable Deaths" (ENAP)" was published in 2014[14]. In 2015, with the purpose of eliminating significant
inequities that lead to disparities in access, quality, andoutcomes of care within and between countries, "Strategies
for Ending Preventable Maternal Mortality" (EPMM) called
for positive political commitments and financial investments
by governments and development partners [15].
In 2015, when the MDGs were about to end, there
emerged the term "Unfinished Business/Unfinished
Agenda" [16,17], and MNCH became again a focal point.
A major issue in global health is undernutrition. The
relation between infant mortality and undernutrition has
been pointed out in the Lancet’s child survival series[2] and reiterated in the MDGs report in 2014 [18]. The
challenge of nutrition has long been a global issue, eversince the adoption of the World Nutrition Declaration
at the FAO/WHO Joint Nutrition Conference in 1992.

Thereafter, there was also a movement to set the goal of"Reducing the proportion of the population suffering fromhunger to half of the 1990 level by 2015" in MDG 1 and"Eradication of extreme poverty and hunger." However,drastic countermeasures have not been taken. In 2008, due
to the publication of the Lancet series of "Maternal andchild undernutrition" [19], several international conferences
dealing with nutrition were held. In 2010, the World Bank
report "Scaling Up Nutrition, What Will It Cost?" pointed outthat investment in nutrition by the global community has
been significantly different from infectious diseases such as
HIV/AIDS [20], thus drawing global attention to nutrition.
Additionally, the movement "1,000 Days Partnership"
globally advocated that the total of around 1,000 days fromthe gestation period to two years of age is particularly
important, on the basis of the theory of DOHaD by Dr.
David Barker [21,22]. Based on this advocacy concept,
the SUN (Scale Up Nutrition) framework was established.
In this framework, 13 cost-effective interventions wererecommended [23]. As for Japan, the government financiallycontributed to the initial establishment of the SUN incooperation with the World Bank. The global discussion on
nutrition was again evoked by the Lancet series "Maternaland Child Nutrition" that included not only undernutrition
but also overweight concerns. This series reiterated theimportance of NCDs in global health [24]. Additionally, theimportance of a wide range of stakeholders beyond thehealth sector was emphasized for roles such as government
sectors, civil society, donor organizations, and private
enterprises [25].

III．SDG era and MCH
Various discussions exist on the post-2015 development
agenda reflecting the MDGs as unfinished. Among them,
the government of Japan emphasized three points: 1)
MDGs brought a certain outcome despite many unsolved
challenges, 2) global societies should address new issues
while continuing to address the remaining issues, and
3) a new agenda should be elaborated based on thecurrent MDGs, with respect for the experiences andlessons learned. Meanwhile, the SDGs were proposedand considered as the new agenda by the United Nations
Sustainable Development Conference (Rio + 20), being
welcomed as the next major global agenda. However, of
the 17 initiatives to be addressed, only SDG 3 "Securing
healthy living for all people of all ages, promoting wellbeing" represented challenges in the health and medical
fields. Other goals that can be related to health included
SDG 2 "End of hunger, achievement of food security
and improvement of nutrition, promotion of sustainable

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Kenzo TAKAHASHI, Marika NOMURA, Sayaka HORIUCHI, Hiroko MIURA
agriculture," SDG 6 "Sustainable water resources andSecuring water and sanitation," etc.. In September 2015,
the SDGs were ratified and announced as the agenda tofollow the MDGs by the UN General Assembly. Therefore,
the viewpoint of "sustainability" was globally recognized
as a common approach. Additionally, the Government ofJapan and WHO advocated UHC as a core agenda of the
SDGs. According to the WHO definition, UHC is "a state
where everyone can receive healthcare services such as
appropriate preventive, therapeutic, rehabilitation, etc. at
the cost that can be paid when necessary." Therefore, it is aformal follower of the concept of primary healthcare (PHC).
As the interest in UHC increases, Japan that has beenachieved and maintained universal health insurance over 50
years was also rising. Finally, the SDGs, launched in 2016
with 17 goals and 169 targets, within which MCH targets
include 1) reduction of the global maternal mortality ratio toless than 70 per 100,000 live births; 2) ending preventable
deaths with neonatal mortality at least as low as 12 per 1,000
live births and under-five mortality at least as low as 25 per
1,000 live births; and 3) ensuring universal access to sexualand reproductive health-care services, including for familyplanning, information, and education, and the integration of
reproductive health into national strategies and programs,
all by 2030 [26].
As for the SDG target of MCH, the "Global strategy for
women's, children's, and adolescents' health (2016–2030)"
was published by "Every Woman, Every Child" in 2015,reflecting the attention for global health communities [27].
This strategy presented a roadmap for ending all
preventable deaths of women, children, and adolescentswithin a generation. It presented three overarching
objectives: survive (end preventable deaths related to MCH
and infectious diseases), thrive (ensure health and wellbeing including nutrition and sexual/reproductive healthservices), and transform (expand enabling environments
including eradication of poverty, access to education,and birth registration). This new strategy emphasizes
adolescents’ health, with the recognition of how theirinvolvement contributes to the health and nutrition of
women, children, and adolescents themselves throughbetter educational attainments, workforce participation,and social enrollment. In other words, a multi-stakeholder
approach was emphasized. This also stresses theimportance of fragile states and humanitarian settings,
because 60% of maternal deaths, 53% of child deaths, and
45% of newborn deaths occur in such situations.

IV．UHC as a global agenda
Nowadays, UHC’s relation to several global challenges
including aging [28], NCDs [29,30], and MCH [31] has beenemphasized. However, as Kieny pointed out, there exists
no one-size-fits-all approach for achieving UHC [32]. For
example, misperceptions exist in Japan’s experiences on thehealth improvement, since Japan is the world’s first country
to achieve universal health insurance in 1961. One of thesemisperception is "Japan’s rapid increase of life expectancy
owes much to the UHC." Additionally, several articles
point out positive correlations between income level andmortality in Japan. However, whether economic growth
explains mortality completely is still debatable [33,34]. In
an ecological time-series study, Sugiura et al. pointed outthat not only medical factors but also non-medical factors,
including education, community-based activities such as
rural improvement movement activities [35], and legislation
contribute positively to life expectancy extension [36].
Another misperception is "Japan’s infant mortality rate
reduction has been achieved with introduction of UHC."
This is also a false perception. As Fig. 1 shows, Japan’s
rapid IMR reduction started before World War II. Basedon our literature review [37], which explored Japan’s pastpolicy and community activities, the determinants of IMR
reduction can be 1) policy commitment by the central
government or 2) synergy effect of community activities
of professional workers, including public health nurses,
practicing midwives, the livelihood extension workers
deployed for rural livelihood improvement, and volunteers.
Additionally, health insurance was already introduced inJapan in the 1920s–1930s, before achieving universal healthinsurance, which made it possible to pool the funds for
employing health professionals, especially public healthnurses. All workers conducted outreach activities forthe community and collected the facts of the community,
which were then transformed into evidence through multi-

Fig.1: Historical trends of Infant Mortality Rate in Japan/1,000livebirth

200
180
160
140
120
100
80

1961:Universal Health Insurance

60
40
20
0

Data Source: e-stat, Japan https://www.e-stat.go.jp/

Data Source: e-stat, Japan https://www.e-stat.go.jp/

Fig.1: Historical trends of Infant Mortality Rate in Japan

398

J. Natl. Inst. Public Health, 66 (4) : 2017

Global policy directions for maternal and child health in the SDG era
stakeholder discussion in the community [38,39]. We
surmise that the contribution of universal health insurance
was: 1) financial back up for employment and maintenanceof public health nurses and 2) accessibility improvement tomedical care in line with the rapid economic growth.
Hereafter, based on the discussion above and reflecting
the current discussion in global health communities,
we focus on the human resources required for healthdevelopment.

V． H u m a n re s o u rc e d e v e l o p m e n t f o rsustainable maternal and child healthcare
As previously mentioned, MCH in global health isdefinitely transforming. On one hand, we should pursue
evidence-based public healthcare considering theevidence from communities, while, on the other hand,
we should implement PDCA cycles based on grasping
current situation, policy/strategy planning, on-the-job
implementation with community activity facilitation,and effectiveness evaluation and from the viewpoint ofcompetent health professional workers at community
level. As pointed out, overcoming the scarcity of humanresources is crucial for service expansion [40]. For
resolving this bottleneck, PHC and volunteer utilization
should be reconsidered, such as in Thailand [41]. Japan’s
past experiences of the community participation of AIIKU
volunteers [38,42] and the field success in India supports
this concept [5]. Their common ground was well-organizedtraining and high quality of activities of the workers in thecommunity.

VI．Conclusion
We reviewed the policy and research directions from
the MDG period to the SDG period. We also identified thetransformation from the concept of MCH to RMNCAH.
RMNCAH services are now gradually reinforced withstrong evidences, including RCT trials and systematic
reviews.
As an SDG agenda, expanding financial protection
coverage may contribute to increased availability of
RMNCAH services, but UHC may not be achievable
without competent healthcare providers. Reflecting fromJapan’s experiences, if effectively designed, the financial
protection scheme will have the potential to retain sufficienthuman resources.
To achieve wider coverage of high-quality RMNCAH
services to communities, we should revisit volunteer
utilization, as well as health professionals with high qualityof activities in PHC.
We declare no conflict of interest.

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SDG 時代の母子保健の世界的政策方向性
高橋謙造 1），野村真利香 2），堀内清華 1），三浦宏子 2）1）帝京大学大学院公衆衛生学研究科
2）国立保健医療科学院国際協力研究部

抄録
2015年， そ れ ま で の 世 界 的 な ア ジ ェ ン ダ で あ る「 ミ レ ニ ア ム 開 発 目 標（MDGs: Millennium
Development Goals）」 が 終 焉 を 迎 え、 新 た な ア ジ ェ ン ダ と し て「 持 続 的 な 開 発 目 標（SDGs:
Sustainable Development Goals）」が国連総会において批准された．本論文では，MDGs時代に母子保健分野が成し遂げた進捗とSDG時代の課題を概観し，日本の過去の母子保健の経験を参照しつ
つ，世界的な母子保健の方向性を検討することを試みた．MDGs時代には，学術誌Lancetの一連のSystematic Reviewの成果，およびインドからの無作為化比較試験（RCT: Randomized Controlled
Trial）の成果等が反映され，エビデンスに基づいた介入の必要性が提言されるに至った．一方で，MDGsの感染症対策等と比して進捗が遅れ気味であった母子保健は，SDGs時代には「残された課題」
として国連レベルで議論されるようになり，"Global strategy for women's, children's and adolescents'
health (2016-2030)"なる戦略書が出版された．この戦略書においては，母子保健分野の３つの目的として，Survive（生存），Thrive（健全な成長），Transform（社会の転換）が提示された．また，SDGs
においては，サービス財源の確保と，サービスの質向上を同時に志向する「ユニバーサルヘルスカバ
レッジ（UHC: Universal Health Coverage）」の実現も提唱され，母子保健への寄与が期待された．しかし，世界で最も早く国民皆保険を実現した日本の経験によれば，国民皆保険導入以前より乳児死亡率等の母子保健指標の改善は始まっており，その改善の背景には保健師，開業助産師によるアウトリー
チ活動を始めとするコミュニティ・レベルでの活動が寄与していた．国民皆保険は，保健師の雇用財源に関して主として寄与した．これらの背景を踏まえて，SDG時代の母子保健では，エビデンスに基づいた母子保健対策が必要となる．また，日本の経験を反映して，UHCの推進だけではなく，プライマリ・ヘルス・ケア（Primary Health Care）に代表されるコミュニティ・レベルでの活動とボラン
ティアの活用も見直すべきである．
キーワード：持続的な開発目標，ユニバーサル・ヘルス・カバレッジ，母子保健，コミュニティ，プライマリ・ヘルス・ケア

J. Natl. Inst. Public Health, 66 (4) : 2017

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