Offline: It's time to hold the private sector accountable

Abstract

Once a central focus of global development goals, the field of women's, children's, and adolescents' health has now been pushed to the margins of international concern. Maternal and child health advocates have been victims of their own success. Steep declines in under-5 mortality and steady progress in reducing maternal mortality have suggested the job is done. While advances in reproductive, maternal, newborn, and child health should be celebrated, this week's report by the Independent Accountability Panel for Women's, Children's, and Adolescents' Health (IAP) proves that such complacency is a grave mistake. The IAP, co-chaired by Carmen Barroso and Kul Gautam, describes how progress, while real, has been desperately uneven. The equity gaps between and within countries should be a source of deep shame for all political leaders and development partners. Children born in the poorest communities are almost twice as likely to die compared with those born in richer settings. 1 million children aged 5–14 years, together with 1·2 million adolescents, die annually, most from preventable causes. 830 women die from pregnancy-related complications every day. And 4·3 billion people will lack access to at least one essential sexual and reproductive health service in their lifetime. These figures are unacceptable. Yet such preventable tragedies have become normalised in our thinking about global health today. Too few people are angry about the fate of women and children in our societies. This year's IAP report focuses on the part played by the private sector in advancing women's and children's health. The Sustainable Development Goals (SDGs) put a premium on strengthening international cooperation (SDG 17 calls for revitalised global partnerships). As the IAP notes, the global health community increasingly looks to the private sector for help in achieving these goals—delivering services, increasing access to medicines, providing food, and developing new technologies. Here lies a contradiction. The private sector creates and sells goods and services. But health is not a commodity to be bought and sold. It is a fundamental human right. How can a private sector dedicated to profit distributed among a small number of shareholders be compatible with the health of all people in all communities? This incompatibility means that private and public sectors will always exist in opposition to one another. While not putting these paradoxical positions quite so starkly, the IAP recognises that this tension must be managed. Its five recommendations—on access to services, the pharmaceutical and food industries, the UN Global Compact, and business engagement—share common principles: the private sector must be subject to higher standards, stronger regulation, minimum legal requirements, increased judicial oversight, greater transparency, and more robust independent national and global accountability. Most importantly, “businesses engaging in the context of universal health coverage must be aligned with one central objective: improving people's health”. The IAP report and its recommendations are important. I hope that WHO's Director-General will make the private sector a special focus of next year's World Health Assembly. It is time for the private sector to be drawn out of the shadows of global health and held accountable for its decisions and actions. What of the IAP itself? Three improvements might be considered. First, although focusing on one specific issue is welcome, the absence of recommendations to address inequitable progress in women's, children's, and adolescents' health is disappointing. Second, governments have primary responsibility for protecting and advancing the health of their citizens. The lack of attention given by the IAP to government failures feels like punches being pulled. The IAP should not be afraid to name and criticise governments (and political leaders) whose decisions have failed to accelerate progress towards better health. Finally, the UN's Every Woman Every Child initiative, valuable as it is, has enabled the private sector to polish its philanthropic credentials. The IAP report would have been stronger if it had evaluated and judged specific private sector promises and commitments. This lack of scrutiny feels like a self-imposed and unnecessary restraint. Independent accountability sometimes means delivering unpalatable and undiplomatic truths. The future health of women and children depends on such unvarnished honesty.